Official Journal of
the British Blood Transfusion Society
16th Annual NATA Symposium on Patient Blood Management, Haemostasis and Thrombosis
Prague, Czech Republic, April 16–17, 2015
Transfusion Medicine | POSTER ABSTRACTS
BLOOD TRANSFUSION SERVICES/RISKS OF TRANSFUSION
P1
Impact of Demographic Changes in Portugal by 2030
on Blood Donation at São João Blood Bank
C. Vaz, F. Vasconcelos, M. Koch, M. Carvalho, C. Neves & F. Araújo
Department of Transfusion Medicine and Blood Bank, Centro Hospitalar
de São João, E.P.E., Porto, Portugal
Introduction: The study of blood donation practices and the charac-
terisation of donors is essential to develop and monitor blood donor
recruitment strategies. The most developed countries are the main con-
tributors, accounting for about half of blood donations all over the world.
In these countries the average donation rate is 39.2 per 1000 inhabitants
and most donations are unpaid and voluntary. Donors are mostly male
and the youth contribute less than adults. In 2013, there was a decrease
in the number of donors and donations in Portugal, with 560 000 blood
donations made by 237 000 donors, and an average rate of 35 dona-
tions per 1000 inhabitants. The donors are most commonly male with
an age from 25 to 44 years old. Since the forecasts indicate an ageing of
the Portuguese population, this work aimed to evaluate the impact of
demographic changes, as expected by 2030, on blood donation.
Methods: We studied the donation activity of São João Blood Bank, the
most active hospital blood bank in the country, responsible for 43% of
the blood donations of the Porto area which has more than a million
of potential donors. The blood bank data between 2008 and 2013 was
retrieved from the blood bank databases. The Portuguese demographic
data was gathered from the Portuguese National Institute of Statistics
and the national database Pordata. National demographic projections for
2030 were carried out in 2012 by a Portuguese group of demographers.
Results: The São João Blood Bank activity has been growing both in
number of donors and donations. In 2013, 24 772 units were collected
from 15 096 active donors. The donation rate was 39.96 per 1000 inhab-
itants. The repeated donor rate has increased significantly, reaching an
average of 1.65 in 2013 and even higher rates in older age groups. Our
typical donor is female (corresponding to 51.1% of the total donors),
between 25 and 44 years old (51.2%), with the equivalent of 1st degree of
basic education. We observed an increase in the educational level in the
last years. It is expected that by 2030 the Portuguese population will not
exceed 10 million and there might be a slight increase in the synthetic
fertility rate and the crude death rate. As a result of these demographic
changes, the number of Portuguese individuals in the eligible age range
for donation (between 18 and 65 years) will decrease from 6 778 560 in
2011 to 5 860 240 in 2030 (13.5% decrease). The age groups under 45
years will have a progressively smaller weight in donations, as opposed
to the donor group over 65 years, whose contribution could be significant
by 2030.
Conclusion: The Portuguese population and the typical donor will be
older in 2030 and the need for transfusion will probably be increased.
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
The donor population is expected to decrease by 13.5% and the age
group over 65 years is expected to increase by 32.3% in the Portuguese
population. According to the recent literature, the donations made by
healthy and regular older donors are equally safe, and therefore São João
Blood Bank should develop a strategy in order to motivate and promote
blood donations among this group.
P2
Awareness of Blood Donation in the Saudi Population:
Current Situation and Future Directions
H. Alsulami & H. Alhatrashi
Al Hammadi Hospital Al-Olaya (AAH), Riyadh, Saudi Arabia
Introduction: In Saudi Arabia, the blood donation system depends
mainly on non-voluntary donors or a so-called a ‘replacement policy’
where the patient’s family or friends donate blood to replace the patient’s
requirement. Such a policy required efforts from patients’ families to find
blood donors. Moreover, the safety of the blood is jeopardised because
such donors might hide some information in order to donate. On the
other hand, implementing a voluntary blood donor system would lead
to a marked decrease in the blood supply because of many reasons
such as the infrastructure for the blood transfusion service, which is
a hospital-based blood banking system, and the awareness of blood
donation among Saudi people. The aim of this study is to assess the level
of awareness of blood donation among Saudis.
Methods: A questionnaire-based cross-sectional study was carried out
in Riyadh, the capital city of Saudi Arabia, from February to June 2014.
The questionnaire was prepared after a review of published reports that
assessed the awareness of blood donation in different countries and was
distributed equally in the four main areas of Riyadh (north, south, east
and west) attracting Saudi people in shopping malls, mosques and other
public places.
Result: Of 475 participants, 67% didn’t know the benefits of blood
donation, 59% didn’t know the location of the blood donation cen-
tre in their area, 49.7% underestimated the length of the blood dona-
tion process, 64.6 didn’t have any idea about the need for blood in
their area or the city, 91.2% didn’t know the date of blood dona-
tion day, and 74% believed that the blood should be free for patients
who need it and patients shouldn’t be asked to replace the blood they
receive.
Conclusion: The study shows that the Saudi population is not enough
aware of the blood donation system as well as the need for blood
in the country. This might be the cause for the low number of vol-
untary blood donors. This study also highlights the need for using
public media to increase the level of awareness, which we miss in
Saudi Arabia.
doi: 10.1111/tme.12183
14 Abstracts of the 16th Annual NATA Symposium
P3
Optimizing Apheresis Donor Scheduling: An Effective
Approach to Increasing Platelet Collections
P. Lokhandwala, H. Shike, R. Domen & M. George
Pennsylvania State University Hershey Medical Center and College
of Medicine, Hershey, PA, USA
Introduction: Apheresis is an effective method to collect platelets. While
platelet-donor recruitment is important in the growth of the programme,
we demonstrate that optimising apheresis donor scheduling also has a
significant impact independent of donor recruitment.
Methods: Retrospective analysis of apheresis collections at the PSHMC
donor centre from the first day of collection in November 2007 (month
0) through July 2014 (month 80) was performed. Following interven-
tions were made: 1) an apheresis instrument added (month 55); 2)
training two additional personnel (month 64); 3) two more collection
days/week added (month 71). The effect was evaluated by monitoring
monthly platelet collections and financial consequences. Mathematical
model is created to predict the effects of altering the apheresis schedule.
Flow-chart to guide intervention decision at other hospital-based donor
centres is also provided.
Results: Identifying saturation of donor schedule: Initially (till month
27), the number of platelet collections rose steadily from 6 to 24/month.
However, between months 28–54, platelet collections showed a plateau
at 25.6 ± 3.1/month. During this plateau phase, our 56 active donors
donated on average 0.46 times/donor/month, which was significantly
lower than the regional average of 0.72 times/donor/month. Lack of
growth was attributed to saturation of the scheduling (average % sched-
ule booked was 66.1 ± 7.9%) rather than limitation of active donors.
Increased scheduling capacity: Interventions collectively resulted in 1)
an increased scheduling capacity (from 39/month to 130/month), 2)
reduction of schedule saturation (from 66.1 ± 7.9% to 36.5 ± 7.8%),
and 3) growth in apheresis collections (from 25.6 ± 3.1/month to
41.0 ± 1.0/months). Financial benefit: Increased platelet collections
offer an annualized financial savings of approximately US$102 500.
Conclusion: Optimising scheduling capacity is an effective strategy to
increase platelet collections, independent of donor recruitment, which
provides significant financial benefit.
P4
Hepcidin/Ferritin Ratio Correlates with Recovery from Iron
Loss Following Blood Donation
R. Lotfi1,2 , C. Kroll2 , D. Plonné3 , B. Jahrsdörfer1,2
& H. Schrezenmeier1,2
1 Institute for Transfusion Medicine, University of Ulm, Ulm, Germany;
2 Institute for Clinical Transfusion Medicine and Immunogenetics Ulm,
German Red Cross Blood Services Baden-Wuerttemberg-Hessen, Ulm,
Germany; 3 MVZ Humangenetik Ulm, Abteilung Laboratoriumsmedizin,
Ulm, Germany
Introduction: Emerging data indicate a higher prevalence of subclinical
iron deficiency (SID) in blood donors. Oral iron supplementation is
recommended for frequent blood donors; however, the term ‘frequent’ is
not well defined and the efficacy of such a treatment is rarely monitored.
Methods: Blood samples were taken at the day of blood donation (day
0), as well as 1, 3, 7, 10 and 56 days thereafter in order to measure: blood
cell count, haemoglobin (Hb), reticulocytes, haemoglobin in reticulo-
cytes (Reti-Hb), erythropoietin (EPO), transferrin, ferritin, twisted gas-
trulation protein homolog 1 (TWSG1), growth differentiation factor-15
(GDF-15) and hepcidin.
Results: Fifty-six days after donation, ferritin level dropped to about 50%
compared to the initial average value, while almost all donors regained
their predonation Hb, making them eligible for a further blood donation.
Even though the average hepcidin level on day 3 significantly dropped
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
to 50% and remained low until day 56, there was a high variation in
individual changes in hepcidin levels. The hepcidin/ferritin ratio on day
3 significantly correlated significantly with ferritin level on day 56. The
group of donors with a hepcidin/ferritin ratio <0.3 regained on average
60% of their initial ferritin after 56 days, while those with a ratio ≥0.3
reached less than 50%.
Conclusion: Our results confirm inter-individual differences in recovery
from iron loss and help to decide whether a blood donor may benefit
from oral iron supplementation or rather from a longer inter-donation
interval.
P5
Seroprevalence of Undiagnosed Transfusion Transmissible
Infections (HIV, Hepatitis B and C, Syphilis) in Donated
Blood in National Blood Banks, Khartoum, Sudan, 2014
D. E. Yousif
Faculty of Medicine, University of Khartoum, Khartoum City, Sudan
Introduction: Transfusion of blood and blood components as a spe-
cialised modality of patient management saves millions of lives world-
wide each year and reduces morbidity. Every year more than 90 million
units of blood are collected worldwide and with each transfusion there
is a risk of transmitting blood-borne pathogens, including mainly HIV,
HBV, HCV and syphilis. The priority objective of blood screening tests
is thus to ensure safety and efficiency of blood supply at all levels. Math-
ematical projection on the overall median risk of becoming infected
with HIV, HBV, and HCV from a blood transfusion in sub-Saharan
Africa is 1, 4.3 and 2.5 infections per 1000 units, respectively. Accord-
ing to this projection, if the annual transfusion requirement projected
by the WHO were met, transfusion alone would be responsible for 28
595 HBV infections, 16 625 HCV infections, and 6650 HIV infections
every year. Currently, prevention of transfusion-transmissible infections
(TTIs) depends up on proper pre-donation selection of donors and sero-
logical testing of infectious markers in those donors. Transfusion depart-
ments have always been a major portal to screen, monitor and control
infections transmitted by blood transfusion. Blood transfusion depart-
ments and blood banks not only screen TTIs but also give clue about the
prevalence of these infections in the population.
Rationale and Methods: We aimed to give an overview of the spread of
TTIs in the Sudanese community by identifying undiagnosed infections
in blood donors coming for donations in a period determined by the
availability of the records in the National Bank, i.e. between January 2012
and June 2014.
Results: A retrospective review of donors’ records identified a high
prevalence of HIV, HBV, HCV and syphilis (0.38%, 3.3%, 0.2% and 2.6%,
respectively) in a total of 126 861 blood samples (Figure), with increased
prevalence of TTIs among replacement donors (54% for replacement vs.
16% for voluntary).
Figure 1. Seroprevalence of immunodeficiency virus, hepatitis B and
C and syphilis (Venereal Disease Research Laboratory, VDRL) among
blood donors (n = 126 861; 93.5% unreactive, 6.5% reactive).
Conclusion: The trends of hepatitis B and syphilis infections show
high, increasing rates in the last year. This may be due to the extensive
population movement and the huge influx of refugees across the border,
and poses important potential hazards to increase in the prevalence of
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

sexually transmitted diseases. In contrast, decreasing rates were found
with regard to HIV and hepatitis C infections, especially in the last
year, with significant lowering trends from 2013 and 2012. These figures
provide clear evidence that we are in an alarming situation and calls
should be made for comprehensive screening of donated blood and a
strict selection of donors, with emphasis on getting young voluntary
donors so it may be possible to reduce the incidence of TTIs at the
national level.
P6
Information Technology in Haemostasis and Transfusion
in Belarus
E. V. Dashkevich, O. V. Krasko, M. S. Rudz & O. N. Bondaruk
The Republican Research Centre of Transfusion and Medical
Biotechnology of Ministry of Health, The State Scientific Institution “The
United Institute of Informatics Problems of the National Academy
of Sciences of Belarus”, Minsk, Republic of Belarus
Introduction: The modern methods of informatics enable comprehen-
sive analysis of medical and diagnostic data, registration of the dynamic
of health parameters of patients, establishing of the optimal treatment
policy, prediction of the disease outcome, assessment of the social and
demographic processes, effective decision-making process on organi-
sational and production levels. National and administrative specifics:
the described tasks are feasible taking into account the compact terri-
tory, the availability of Internet, the number of administrative regions
(7), the constantly improving policy framework, the potential of human
resources and the computer skills of medical staff.
Development of information technology in the health care in the Repub-
lic of Belarus has passed several stages: creation of automated registers,
development of information analytical systems (IAS) based on registers
with the pharmacological and economic models for calculating patient’s
need for replacement therapy (for example, to relief the instance of bleed-
ing according to the clinical protocol of treatment for patients with
haemophilia A and B), creation of organisational and methodological
structure of the service, intergovernmental informational cooperation
in the field of diagnostics and decision making. The establishment of
the Register of Post Transfusion Reactions and Complications (RPTC) is
focused not only on clinical practice, but also on production, as it helps
to determine the ways to improve the procurement and processing of
blood.
Objective: To study the nature and prevalence of post-transfusion com-
plications and transfusion reactions (PTC) in hospitals of the Republic
of Belarus with IAS RPTC.
Materials: Data on the incidents of PTC in the country.
Results: The incidents of PTC depend on the diagnosis: haematol-
ogy (29.94%), therapy (21.4%), surgery (15.79%), orthopaedics (2.33%),
urology (2.3%), burns (0.65%), gynaecology and obstetrics (3.31%).
Depending on the transfusion medium: erythrocytes containing medi-
ums (50%), fresh frozen plasma (35.7%), thrombocytes containing
mediums (10%), other mediums (7.7%). 65.5% of the incidents were
characterised by febrile reactions, 30% by allergic, 0.5% by TRALI. PTC
frequently occurred in the age group older than 46 years old (59%) and
18-45 years old (31%). In age groups under 18 and over 70 years old:
10% and 12%, respectively. Incidents of hepatitis B among patients with
haemophilia A: 25% hepatitis C, 1.6% hepatitis B.
Future tasks for further introduction of information technology methods
in the field are to improve organisational and methodological structures
of the blood service and coordination between regions; compilation of
summary tables and trend indicators of the use of hospital beds, person-
nel, transfusion activity, efficiency of the new methods of blood storing
and processing; dynamic mode accumulation, storage and processing of
information about donors by standardised methods.
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 15
P7
High Titres of Anti-HLA-I/-II IgG in Different Preparations
of IVIg: Can It Be Used for Transfusion and for Lowering
the Anti-HLA IgG in Sensitised Pre-transplant Patients?
M. H. Ravindranath, P. I. Terasaki, C. Y. Maehara & V. Jucaud
Terasaki Foundation Laboratory, Los Angeles, CA, USA
Introduction: Sera of non-alloimmunised healthy individuals contain
anti-HLA-I & -II IgG and therefore it is reasonable to expect HLA-I/-II
reactivity of intravenous immunoglobulin (IVIg). However, the titres
at which anti-HLA-I & -II IgG occur in IVIg preparations used for
transfusion or for renal failure patients with purpose of lowering HLA
antibodies was not evaluated. Possibly this could be the reason for
failure of IVIg to lower anti-HLA IgG in sensitised patients. High titres
of anti-HLA-I/-II IgG in IVIg may place transplant patients at risk
for endothelial damage as observed in patients and animal models of
IVIg-transfusion-related acute lung injury.
Methods: Herein, we analysed several commercial preparations of IVIg
and sera of non-alloimmunised males for 1) HLA-Ia & Ib reactivity,
2) HLA-II reactivity, 3) IgG isotype characterisation using multiplex
Luminex®-based immunoassay. Reliability of secondary antibodies tar-
geting H & L chains of IgG and Fc𝛾2AB domain were examined for
monitoring of anti-HLA antibodies and IgG isotypes.
Results: IVIg preparations and the purified-IgG and the native sera
showed that HLA-IgG antibodies occur in the following order of
frequency: DPA (80%), DQA (71%), DRB345 (67%), DQB (57%),
Cw (50%), DBP (43%), DRB1 (21%), A (14%), and B (7%). Indeed,
the therapeutic preparations of IVIg used for transplant patients had
high titres of HLA-I/-II IgG, as follows: Gamastan = Gamunex (2
lots) < Octagam ≪ Sandaglobulin. The highest titre of HLA-II IgG
in different therapeutic preparations of IVIg were observed against
DRB3*03:01, DQA1*01:02\DQB1*06:02 and DPA1*02:01/DPB1*23:01,
exactly similar to that seen for the purified and native sera of all (n = 15)
healthy males. The anti-HLA IgG isotypes in IVIg, in purified and
unpurified sera of non-alloimmunised males differed in the following
order: IgG1 > IgG2a > IgG3 > IgG4. These results postulate the risks
involved in transfusing IVIg and particularly for the purpose of lowing
HLA antibodies in sensitised patients and stipulate re-evaluating the
use of IVIg in transplantation.
Conclusions: It should be implemented that the preparations should be
monitored, prior to use, for the profile and titres of anti-HLA-I/-II IgG
for any IVIg preparation used for transfusion or transplantation, whether
at low or high doses and preferably the HLA-reactivity of IVIg should be
examined in the context of HLA typing of recipients.
P8
Platelet Haemostatic Activity Falls in Stored Platelet
Concentrates
E. V. Roitman1 , I. M. Kolesnikova2 & S. A. Roumiantsev1,2
1 Pirogov Russian National Research Medical University, Moscow, Russia;
2 Federal Scientific and Clinical Centre on Paediatric Haematology,
Oncology and Immunology n.a. D.Rogachev, Moscow, Russia
Introduction: Platelets transfusions are not always successful to stop the
bleeding although platelets retain metabolic activity in stored platelet
concentrates (PCs). One of reasons might be the loss of haemostatic
capacities of platelets.
Aim: To study the platelets haemostatic capacities reflecting from
metabolic changes due to platelet concentrates storage.
Methods: Fifty single-donor apheresis and leucoreduced PCs were
divided in two groups: in group 1, platelets remained in autologous
plasma (PCs-P; n = 26); in group 2, platelets were re-suspended in
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
16 Abstracts of the 16th Annual NATA Symposium
PAS (SSP+; Macopharma, France) which is substituted up to 70 vol%
of autoplasma (PCs-PAS; n = 24). Storage conditions were equal for
both groups. PCs samples were analysed by modified thromboelastog-
raphy and by aggregometry, and for platelets count, pH, lactate, glu-
cose, platelets parameters and acid–base parameters. PCs samples were
assayed on the day of proceeding, after 24 hours and on the third and
fifth days of storage. Because the internal conditions differed in PCs we
considered the degrees of changes that reflected the dynamics of the pro-
cesses. At the use of MedCalc (MedCalc Software, Belgium) the dates
were present as median (CI 95%), and statistical differences were calcu-
lated using Mann-Whitney test (p < 0.05), and regression analysis was
performed.
Results: No differences were in platelets morphological parameters
from various PCs groups. From the day of producing to the 5th days of
storage glucose decreased in PCs-P from 18.3 mmol/L to 9.4 mmol/L
(–48.6%), and in PSc-PAS from 5.2 mmol/L to 1.3 mmol/L (–52%),
and lactate concentration had the increase in PCs-P from 2.7 mmol/L
to 16.4 mmol/L (6-fold up), and in PCs-PAS from 1.4 mmol/L to
9.6 mmol/L (6/9-fold up). In both PCs the aggregation response was
equal at the day of producing. Then aggregation activity become
progressively less with minimum achieved at 5th day of storage. Clot
formation rate slowed down, MA have declined, and the module G was
decreased that indicated to deterioration of clot properties (–32% and
–41% in PCs-P and PCs-PAS, respectively). In PCs-P clot properties
were under the influence of platelet aggregation, platelet morphology
and environment properties during only the first 3 days. In PCs-PAS no
such influence was manifested in general.
Conclusions: Clot properties, platelet aggregation and platelet adhesion
have worsened during PCs storage despite the method of producing. Clot
properties do not depend directly from platelet aggregability and adhe-
sion. Therefore, we assume that successful in vivo recovery of platelet
activity determines final haemostatic effect of platelet transfusion. The
last assumption will be tested in a future study.
P9
Decline of Cell Number and Cellular Properties
of Blood-banked Red Blood Cells of Different Cell Ages
during Storage
W.-W. Tuo, D. Wang, W.-J. Liang & Y.-X. Huang
Department of Biomedical Engineering, Ji Nan University, Guang Zhou,
China
Introduction: Numerous studies have suggested that transfusion of red
blood cells (RBCs) stored over a long period of time may induce harmful
effects due to storage-induced lesions. However, the underlying mecha-
nisms responsible for this damage have not been identified. Furthermore,
it is unclear why and how up to 30% of RBCs stored for a long period of
time disappear from the circulation within 24 hours after transfusion.
The aim of this study was to determine how the cell number of RBCs of
different ages changes during storage and how these cells undergo cumu-
lative structural and functional changes with storage time.
Methods: We used Percoll centrifugation to fractionate the RBCs in
stored RBC units into different aged sub-populations and then measured
the number of intact cells in each sub-population as well as the cells’
biomechanical and biochemical parameters as functions of the storage
period.
Results: We found that the RBC units stored for ≤14 days could be
separated into four fractions: the top or young cell fraction, two middle
fractions, and the lower or old fraction. However, after 14 days of storage,
the cell number and cellular properties declined rapidly whereby the
units stored for 21 days only exhibited the three lower fractions and
not the young fraction. The cell number within a stored unit decreased
by 23% compared to a fresh unit and the cells that were lost had
haemolysed into harmful membrane fragments, microparticles and free
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
haemoglobin. All remaining cells exhibited cellular properties similar to
those of senescent cells.
Conclusion: In RBC units stored for greater than 14 days, there were
fewer intact cells with no healthy cells present as well as harmful mem-
brane fragments, microparticles and free haemoglobin. Therefore, trans-
fusion of these stored units would not likely help patients and may induce
a series of clinical problems.
P10
Autologous Transfusion of Stored Red Blood Cells Increases
Pulmonary Artery Pressure
R. Pinciroli, L. Berra, C. Mietto, B. Yu, M. Sherrer-Crosbie, C. Stowell &
W. M. Zapol
Department of Anesthesia, Critical Care and Pain Medicine,
Massachusetts General Hospital, Boston, MA, USA
Introduction: Transfusion of erythrocytes stored for prolonged periods
is associated with increased mortality. Packed red blood cells (PRBC)
undergo haemolysis during storage and after transfusion. Plasma
haemoglobin (Plasma-Hb) scavenges endogenous Nitric Oxide (NO)
leading to vasoconstriction. We primarily hypothesised that transfusion
of autologous PRBC stored for 40 days would increase the pulmonary
artery pressure (PAP) in volunteers with endothelial dysfunction
(impaired endothelial NO production) determined by a reduced reac-
tive hyperaemia index (RHI). We also tested whether inhaled nitric
oxide (iNO) could prevent the increase of PAP. Secondary endpoints
aimed to assess the influence of storage age on plasma NO metabolites
(NOx), NO consumption (NOc), iron metabolism, renal and hepatic
function, and inflammation.
Methods: 57 volunteers were screened to enrol 14 obese adults with
endothelial dysfunction (RHI < 1.8) in a randomised crossover study
of transfusing autologous, leucoreduced PRBCs stored for either 3 or
40 days. Volunteers were auto-transfused 3 times, over a period of
8 months, with (a) 3-day blood, (b) 40-day blood, and (c) 40-day
blood + 80 ppm iNO. Mean PAP was estimated by transthoracic echocar-
diography (TTE) at baseline and at the end of transfusion. Venous blood
was sampled before and at 10 min, 1 h, 2 h, 4 h and 24 h after transfusion.
Plasma-Hb, a comprehensive metabolic panel, complete blood count,
plasma cytokines, serum iron, non-transferrin bound iron (NTBI), hep-
cidin, haptoglobin, neutrophil gelatinase-associated lipocalin (NGAL),
and NOx were measured at every time point. NOc was measured at base-
line, 10 min and 4 h after transfusion.
Results: The age of volunteers was 41 ± 4 years (BMI 33.4 ± 1.3 kg/m2 ).
Plasma-Hb increased after transfusion with 40-day and 40-day + iNO
blood, but not after transfusing 3-day blood. Mean PAP increased after
transfusing 40-day blood (18 ± 2 to 23 ± 2 mmHg; p < 0.05), but did not
change after transfusing 3-day blood (17 ± 2 to 18 ± 2 mmHg; p = 0.5).
Breathing iNO decreased PAP in volunteers transfused with 40-day
blood (17 ± 2 to 12 ± 1 mmHg; p < 0.05). Endothelial dysfunction was
associated with low levels of NOx at baseline and NOx remained low
after transfusion of 40-day blood. Breathing iNO immediately increased
plasma nitrate levels but not nitrite levels. Plasma NOc increased at 4 h
after transfusion of 40-day blood (p < 0.001), while no difference was
detected when volunteers received 3-day blood or breathed iNO. Iron
levels (μg/dL) and NTBI (𝜇M) were significantly increased, peaking
at 4 h after transfusion with 40-day blood as compared to baseline
and 3-day blood (p < 0.0001). Hepcidin (ng/mL) was also significantly
increased at 24 h after 40-day challenges compared to both baseline and
3-day blood (p < 0.05). Autologous stored PRBC did not alter plasma
levels of haptoglobin, inflammatory cytokines or renal and hepatic injury
markers.
Conclusions: Transfusion of autologous leucoreduced PRBC stored for
40 days was associated with increased plasma haemolysis and increased
pulmonary artery pressure. Breathing nitric oxide prevents the increase
of pulmonary artery pressure produced by transfusing stored blood.
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

P11
Frozen Platelets – New Challenge and Progressive
Alternative in the Blood Component Supply
M. Bohonek, M. Koranova, L. Landova, E. Staskova & E. Sladkova
Department of Haematology and Blood Transfusion, Central Military
Hospital, Military University Hospital, Prague, Czech Republic
Introduction: Massive bleeding and massive transfusion are associated
with increased morbidity and mortality in severely injured patients.
Early and aggressive use of blood products in these patients may cor-
rect coagulopathy, control bleeding and improve outcomes. Majority is
preventable if red cells, plasma and platelets are available as soon as pos-
sible. Due to their very short shelf life, having a daily stockpile of fresh
platelets is not possible for many hospital blood banks. The alternative
solution is a stock of frozen platelets which are successfully used in mil-
itary medicine.
Methods: Apheresis leucodepleted platelets, with >280 x 109 thrombo-
cytes/unit, are (after a removal of supernatant) frozen in –80 ∘ C, with 5%
DMSO, and stored at the same temperature for up to 2–4 years. For clin-
ical use, there are thawed platelets, preferably group O, reconstituted in
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 17
thawed plasma, group AB. The reconstitution is a simple process which
consists of thawing platelets and plasma in water bath and adding plasma
into platelets under mixing. The whole procedure takes 30 minutes at
most. Shelf life of reconstituted frozen platelets is 6 hours, during stor-
age in 20–24 ∘ C and agitation. Before the routine use, we performed a
validation study with 15 produced units of frozen platelets. All 15 units
of checked platelets meet specified criteria. Compared to fresh aphere-
sis platelets, frozen platelets are (partially) activated, clot strength mea-
sured by TEG with citrated kaolin is reduced, and onset of clotting and
clot amplification is faster. Since September 2014 we have used frozen
platelets in routine practice and collected clinical and laboratory data.
Conclusion: Frozen platelets are a beneficial alternative, not only for
military blood banks but also for civilian blood banks which do not have
a permanent stock of fresh platelets available. Due to a relatively easy
preparation, the cost of frozen platelets is not high and their storing in
small portable deep freezers does not bring any significant additional
expenses. Procedure of thawing and reconstitution of frozen platelets is
very simple and fast, and it allows for having quality platelets products
when dealing with massive bleedings and other urgent as well as for
another special indication.
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
18 Abstracts of the 16th Annual NATA Symposium

TRANSFUSION PRACTICE

P12 immunosuppression in recipients, while cost of blood screening and

storage is high. On the other hand, elderly patients may have impaired
Written Informed Consent for Blood Transfusion Could
physical status and increased demand for packed red blood cell (PRBC)
Improve Compliance with Valid Consent Process transfusion.
H. Qureshi, P. Sharp, F. Waller, M. Browett, M. Chambers & J. Reid Objectives: The aim of our retrospective observation study was to test the
Department of Transfusion Medicine, University Hospitals of Leicester hypothesis that a correlation exists between PRBC transfusion and age,
NHS Trust, Leicester, UK in our both medical and surgical ICU served in community hospital.
Introduction: Blood transfusion carries potential risks. In 2007, the UK Methods: From 2005 to 2014 admitted to our ICU 698 patients. Mean
department of Health’s circular (HSC 2007/001) required hospitals to age (years) 63.82, mean APACHE II score on admission: 20.25, mean
ensure that patients are well informed of the risks and benefits of blood length of ICU stay (LOS, days): 13.45, mean duration of mechanical
transfusion and that such discussion is clearly documented in their clini- ventilation per patients ventilated (VD, days): 11.63. From our database
cal records. In 2011, the UK Advisory Committee on Safety of Blood, Tis- we looked for the age and the following values and indexes according
sues and Organs (SaBTO) reinforced this recommendation. While these PRBC per year from 2005 to 2014 (mean values): PRBC crossmatched
recommendations did not stipulate a ‘written consent’ per se, valid con- and transfused: total, per patient, per hospitalisation day (HD), per
sent requires the provision of appropriate information on risks and ben- patient on mechanical ventilation (MV), per ventilation day (VD) and
efits of proposed transfusion to patients, as well as any transfusion alter- the crossmatched/transfused ratio. Using linear correlation method, we
native strategies, which might be suitably available; with clear documen- looked for linear slope, correlation coefficient (r), and coefficient of
tation of such a discussion in the patient’s healthcare records. However, determination (r2 ), and by linear regression method using ANOVA test
previous institutional audits of blood transfusion consent and anecdotal we looked for p value, according age and PRBC transfusion.
experience suggests that patients are rarely given adequate information Results: Correlation between age and PRBC transfusion and cross-
about risks and benefits of transfusion, and where this information is matched indexes.
provided, its quality and content is variable and documentation is often
poor. The recent UK national audit of informed consent for blood trans- St. p
fusion reported an overall compliance for 43% of all transfusion episodes PRBC Slope r r2 Error L. CI U. CI value
audited (n = 2784), while only a small minority of hospitals which con-
tributed to the national audit, had a policy for ‘written’ consent. In our Total crossmatched 14⋅51 0⋅680 0⋅463 5⋅380 1⋅740 26⋅56 0.0302
institution we implemented a policy for informed written consent for Total transfused 9⋅20 0⋅634 0⋅402 3⋅96 0⋅067 18⋅33 0.0467
blood transfusion in May 2011. We audited compliance with this policy Crossmatched per 0⋅120 0⋅572 0⋅327 0⋅06 −0⋅02 0⋅260 0.0838
in 2013–2014 and present our results. patient
Methods: Our institutional policy for obtaining informed written con- Transfused per patient 0⋅086 0⋅429 0⋅052 0⋅052 −0⋅035 0⋅208 0.1420
sent for blood transfusion involves an interaction between the healthcare Crossmatched per HD 0⋅003 0⋅321 0⋅103 0⋅003 −0⋅005 0⋅012 0.3651
professional and the patient during which potential risks and intended Transfused per HD 0⋅003 0⋅321 0⋅103 0⋅003 −0⋅004 0⋅011 0.3652
benefits of transfusion are discussed, using a standardised transfusion Crossmatched per 0⋅112 0⋅531 0⋅282 0⋅006 −0⋅033 0⋅257 0.1135
consent tool, and patients are offered written information. Following the patient on MV
discussion the patient is asked to sign a standard consent form which Transfused per patient 0⋅085 0⋅471 0⋅222 0⋅056 −0⋅044 0⋅215 0.1692
highlights the risks, benefits and any applicable transfusion alternative on MV
strategies. We carried out a prospective audit of compliance with our pol- Crossmatched per VD 0⋅008 0⋅451 0⋅204 0⋅006 −0⋅005 0⋅022 0.1900
icy for informed written consent from late 2013 to early 2014. Data was Transfused per VD 0⋅006 0⋅407 0⋅165 0⋅005 −0⋅005 0⋅018 0.2431
prospectively collected for 98 randomly selected transfusion episodes in Crossmatched/ −0⋅028 −0⋅332 0⋅1105 0⋅028 −0⋅093 0⋅037 0.3480
medical and surgical patients, using a standardised audit tool. transfused ratio
Results: Our audit demonstrated an overall compliance with the require-
ment for informed written consent in 79% (81/98) of transfusion Conclusion: According to our data, there was no statistically signifi-
episodes audited. cant correlation detected between age and PRBC transfusion and cross
Conclusion: Our data shows that it is possible to implement an institu- matched indexes, nor cross matched over transfused. On the other
tional policy for standardised written informed consent for blood trans- hand, there was statistical significant, moderate positive linear correla-
fusion, and suggests that such a policy could improve compliance with tion detected between age and total amount of PRBC cross matched and
the process for obtaining a valid informed consent. transfused. Our data suggest that even though transfusion per patient
doesn’t correlate with age, some older patients need more PRBC.
P13
Correlation between Packed Red Blood Cell Transfusion
and Age in Intensive Care Unit Patients P14
A. Vakalos & D. Nikitidis Correlation between Packed Red Blood Cell Transfusion
Intensive Care Unit, Xanthi General Hospital, Xanthi, Greece and APACHE II Score in Intensive Care Unit Patients
Introduction: Transfusion is not risk free, and is associated with aller- A. Vakalos & D. Nikitidis
gic reactions, lung injury, infectious disease, circulatory overload and Intensive Care Unit, Xanthi General Hospital, Xanthi, Greece

Transfusion Medicine, 2015, 25, Suppl. 1, 13–54 © 2015 The Authors

Transfusion Medicine © 2015 British Blood Transfusion Society
 Abstracts of the 16th Annual NATA Symposium 19

Introduction: Transfusion is not risk free, and is associated with aller- Objectives: The aim of our retrospective observation study was to test the
gic reactions, lung injury, infectious disease, circulatory overload and hypothesis that a correlation exists between PRBC transfusion and LOS,
immunosuppression in recipients, while cost of blood screening and in our both medical and surgical ICU served in community hospital.
storage is high. On the other hand, high severity grade patients may have Methods: From 2005 to 2014 admitted to our ICU 698 patients. Mean
impaired physical status and increased demand for packed red blood cell age (years) 63.82, mean APACHE II score on admission: 20.25, mean
(PRBC) transfusion length of ICU stay (LOS, days): 13.45, mean duration of mechanical ven-
Objectives: The aim of our retrospective observation study was to test tilation (VD, days): 11.63. From our database we looked for the LOS and
the hypothesis that a correlation exists between PRBC transfusion and the following values and indexes according PRBC per year from 2005
the most common used severity index, APACHE II score on admission, to 2014 (mean values): PRBC crossmatched and transfused: total, per
in our both medical and surgical ICU served in community hospital. patient, per hospitalisation day (HD), per patient on mechanical venti-
Methods: From 2005 to 2014 admitted to our ICU 698 patients. Mean lation (MV), per ventilation day (VD) and the crossmatched/transfused
age (years) 63.82, mean APACHE II score: 20.25, mean length of ICU stay ratio. Using linear correlation method, we looked for linear slope, corre-
(LOS, days): 13.45, mean duration of mechanical ventilation (VD, days): lation coefficient (r), and coefficient of determination (r2 ), and by linear
11.63. From our database we looked for the APACHE II score and the fol- regression method using ANOVA test we looked for p value, according
lowing values and indexes according PRBC per year from 2005 to 2014 LOS and PRBC transfusion.
(mean values): PRBC crossmatched and transfused: total, per patient, Results: Correlation between LOS and PRBC transfusion and cross-
per hospitalisation day (HD), per patient under mechanical ventilation matched indexes.
(MV), per ventilation day (VD) and the crossmatched/transfused ratio.
Using linear correlation method, we looked for linear slope, correla-
tion coefficient (r), and coefficient of determination (r2 ), and by linear St. p
regression method using ANOVA test we looked for p value, according
PRBC Slope r r2 Error L. CI U. CI value
APACHE II score and PRBC transfusion.
Results: Correlation between APACHE II score and PRBC transfusion Total crossmatched 19⋅450 0⋅384 0.147 16⋅521 −18⋅04 57⋅55 0.2728
and crossmatched indexes. Total transfused 14⋅369 0⋅407 0.165 11⋅401 −11⋅921 40⋅65 0.2431
Crossmatched per 0⋅3391 0⋅659 0.434 0⋅1368 −0⋅6591 0⋅6545 0.0382
patient
St. p Transfused per 0⋅2740 0⋅650 0.423 0⋅0031 0⋅0131 0⋅5349 0.0417
PRBC Slope r r2 Error L. CI U. CI value patient
Crossmatched per 0⋅0077 0⋅278 0.077 0⋅0094 −0⋅014 0⋅0296 0.4333
Total crossmatched 17⋅725 0⋅6123 0⋅3749 8.092 −0.934 16.384 0.0599 HD
Total transfused 11⋅573 0⋅5732 0⋅3286 5.849 −1.914 25 0.0832 Transfused per HD 0⋅0108 0⋅416 0.175 0⋅0083 −0⋅008 0⋅030 0.2289
Crossmatched per 0⋅059 0⋅2017 0⋅0040 0.101 −0.175 0.294 0.5763 Crossmatched per 0⋅2995 0⋅582 0.335 0⋅1476 −0⋅582 0⋅3398 0.0770
patient patient on MV
Transfused per patient 0⋅045 0⋅1897 0⋅0360 0.836 −0.147 0.238 0.5996 Transfused per 0⋅2674 0⋅606 0.367 0⋅1239 −0⋅0183 0⋅5533 0.0630
Crossmatched per HD −0⋅001 −0⋅068 0⋅004 0.005 −0.014 0.011 0.8519 patient on MV
Transfused per HD 0⋅000 0⋅032 0⋅001 0.005 −0.011 0.012 0.9290 Crossmatched per 0⋅0230 0⋅496 0.246 0⋅0142 −0⋅009 0⋅055 0.1442
Crossmatched per 0⋅045 0⋅1562 0⋅024 0.402 −0.190 0.282 0.6665 VD
patient on MV Transfused per VD 0⋅020 0⋅539 0.290 0⋅0113 −0⋅005 0⋅046 0.1077
Transfused per patient 0⋅043 0⋅1716 0⋅029 0.087 −0.159 0.245 0.6355 Crossmatched/ −0⋅122 −0⋅588 0.346 0⋅059 −0⋅258 0⋅014 0.0733
on MV transfused ratio
Crossmatched per VD 0⋅001 0⋅052 0⋅002 0.009 −0.020 0.023 0.8853
Transfused per VD 0⋅001 0⋅074 0⋅005 0.007 −0.016 0.019 0.8371
Conclusion: According to our data, there was statistical significant,
Crossmatched/ −0⋅041 −0⋅347 0⋅120 0.039 −0.131 0.049 0.3252
moderate positive linear correlation detected between LOS and PRBC
transfused ratio
both cross matched and transfused. On the other hand, there was no
statistically significant correlation detected between LOS and the rest
Conclusion: According to our data, there was no statistically significant PRBC transfusion and cross matched indexes, nor the total amount of
correlation detected between APACHE II score and PRBC transfusion PRBC crossmatched and transfused. Our data suggest that the more the
and cross matched indexes, nor cross matched over transfused. On the PRBC transfused, the longer the LOS, but not vice versa.
other hand, there was detected as a trend but not statistical significant,
weak positive linear correlation between APACHE II score and total
amount of PRBC crossmatched. Our data suggest that the more severe P16
the illness, the more PRBC crossmatched but not transfused.
Abstract withdrawn

P15
Correlation between Packed Red Blood Cell Transfusion
and Length of Stay in Intensive Care Unit Patients
A. Vakalos & D. Nikitidis
Intensive Care Unit, Xanthi General Hospital, Xanthi, Greece
Introduction: Transfusion is not risk free, and is associated with aller-
gic reactions, lung injury, infectious disease, circulatory overload and
immunosuppression in recipients, while cost of blood screening and
storage is high. On the other hand, patients who need long ICU hos-
pitalisation (length of stay, LOS), may have impaired physical status and
increased demand for packed red blood cell (PRBC) transfusion.
P17
Differential Transfusion Triggers Obey Biologic Variability
in Elderly Recipients
U. Nydegger, P. Medina Escobar, L. Risch & M. Risch
Labormedizinisches Zentrum Dr. Risch, Bern-Liebefeld, Switzerland
Introduction: Biologic variability in the elderly: a perspective to set
age-adapted transfusion trigger values for haemoglobin and PLT count
utilised for prescription of RBC and/or PLT concentrates.
Methods: Apparently healthy 557 men and 722 women ≥60 years partic-
ipating in our Senior Labor Study (www.seniorlabor.ch) in whom CBC

© 2015 The Authors Transfusion Medicine, 2015, 25, Suppl. 1, 13–54

Transfusion Medicine © 2015 British Blood Transfusion Society
20 Abstracts of the 16th Annual NATA Symposium
was assessed using an XE-5000 haematology analyser (Sysmex-Digitana,
Switzerland). An attempt is made to update the biologic variability of
haematology parameters in human senescence.
Results: Reference intervals (RIs) were stratified according to age
and gender. Double-sided 95% reference intervals for men were:
129–168 g/L (age 60–69), 125–168 g/L (age 70-79) and 118–169 g/L
(age ≥80). The respective RIs for females were: 120–157 g/L (age
60–69), 116–156 g/L (age 70–79) and 115–164 g/L (age ≥80), deviat-
ing from RIs issued by WHO. A linear regression model incorporating
age, female gender, testosterone, ferritin, CRP, ALAT, cholinesterase,
and total bilirubin were identified as significant predictors (all p < 0.01)
of haemoglobin concentrations accounted for 37.4% of haemoglobin
concentration variance.
Conclusion: Mild anaemia in healthy elderly citizens sets the stage for
overtransfusion. Trigger levels of haemoglobin, haematocrit and PLT so
far established in guidelines are often depreciative of individual biolog-
ical variation, under influence of e.g. circadian cycle, BMI and individ-
ual variability. Comorbidities, more frequent in geriatrics, mild forms of
well-tolerated chronic anaemia in patients with elective surgery may well
require prior iron substitution rather than belated RBC transfusion.
P18
Extracorporeal Membrane Oxygenation Therapy and Red
Blood Cells Transfusion
V. Guilló, P. Castelló, M. Ortega, A. Blanco, S. Arango & A. Peral
Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
Background: Normal haemoglobin levels are suggested in patients on
extracorporeal membrane oxygenation (ECMO). In contrast, current
transfusion guidelines for critically ill patients recommend restrictive
transfusion practice. In a recent study on a series of 18 patients receiving
veno-venous (VV) ECMO for acute respiratory distress syndrome, a
restrictive transfusion protocol did not result in increased mortality.
Material and Methods: Transfusion management of 25 patients on
ECMO therapy from March 2012 to December 2014 was retrospectively
analysed. Statistical analysis was done with SPSS 20. All categorical vari-
ables were compared using Fisher’s exact test or 𝜒 2 test, continuous vari-
ables were compared using Student’s t test for paired and for independent
samples.
Results and Discussion: Among 25 patients, 21 were treated with
veno-arterial (VA) ECMO (84%), 4 cases were on VV device (16%),
with an median length on circulatory assist therapy of 8 days (aver-
age 10.2 ± 10.3 days). Mean red blood cell (RBC) transfusion during
ECMO therapy was 17.1 ± 15.6 units. We found a significant intraop-
erative decrease in haemoglobin levels (12.7 ± 2.9 vs. 10.1 ± 2.1 g/dL;
p < 0.001). Intraoperatively, 13 patients (52%) needed RBC transfusion,
5.9 ± 8.4 units were administrated on average, median of to 2 RBC units
were administrated. Two cases required 24 and 25 units due to techni-
cal complications. Postoperative transfusion rate was 88%, 3.7 ± 5.3 RBC
units for the first 48 hours, and 13.9 ± 11.9 thereafter. Transfusion trigger
was 8.2 ± 0.8 g/dL in our cohort.
Conclusion: Patients on ECMO therapy require a high amount of RBC
units intra and postoperatively, even when a restrictive approach is used.
REFERENCES
Smith A, Hardison D, Bridges B, Pietsch J. Red blood cell transfusion vol-
ume and mortality among patients receiving extracorporeal membrane
oxygenation. Perfusion 2013;28:54-60.
Voelker MT, Busch T, Bercker S, Fichtner F, Kaisers UX, Laudi S. Restric-
tive transfusion practice during extracorporeal membrane oxygenation
therapy for severe acute respiratory distress syndrome. Artif Organs 2014
Oct 27 [Epub ahead of print].
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
P19
High-dose Chemotherapy Does Not Increase Total Blood
Requirements in Patients with Acute Leukaemia during
Disease Process: A Nationwide Database Study
J.-S. Lin & T.-J. Chiou
Divisions of Transfusion Medicine and Haematology, Department
of Medicine, Taipei Veterans General Hospital, National Yang-Ming
University School of Medicine, Taipei, Taiwan, ROC
Introduction: High-dose chemotherapy may induce severe cytopenia
and need blood component support. Whether high-dose chemotherapy
will increase overall blood component requirements from diagnosis to
death was rarely reported.
Methods: The data were retrieved from Taiwan Longitudinal Health
Insurance Database. This nationwide survey randomly selected 98
patients who were newly diagnosed with acute leukaemia between
2005 and 2010. The follow-up period extended to 31 December 2011.
The patients with age less than 20 years old or survival less than 100
days were excluded. Transfusion amounts in subgroups (grouping
by gender, age, or high dose chemotherapy) were compared by the
Mann–Whitney U test. The patients who received at least one cycle of
high-dose chemotherapy were classified as high-dose chemotherapy
group.
Results: We evaluated 98 consecutive patients (female: 41, male: 57;
median age: 52.5 years, range of age: 20–86 years) with acute leukaemia
(acute lymphoid leukaemia, ALL: 15 patients, acute myeloid leukaemia,
AML: 83 patients). Thirty patients received at least one cycle of high-dose
chemotherapy. Majority patients (n = 96) expired. Median survival of all
patients was 307 days. High-dose chemotherapy does not produce better
overall survival (median survival: 328 vs. 311 days; p = 0.135). Trans-
fusion amounts of packed RBC (PRBC) and platelets pheresis (PltPh)
were similar between female and male. PRBC requirement were higher
in older patients (age >50 years) than younger patients (median: 45 vs. 20
units, p = 0.005). Patients with high-dose chemotherapy received similar
amounts of PRBC and PltPh than those without high-dose chemother-
apy during disease process.
Conclusions: High-dose chemotherapy did not increase total PRBC and
PltPh requirements during disease process compared with conventional
chemotherapy.
P20
Overview of Annual Usage of Cellular Blood Components
in a Norwegian University Hospital
A. Espinosa, F. Rekstad, M. Petersen, B. Sletta & B. Dybvik
St. Olav’s University Hospital, Trondheim, Norway
Introduction: Optimisation of blood usage is an important part of the
hospital’s patient management programme, and starts with an evaluation
of the actual blood usage. To date, no systematic stratification of the data
regarding blood transfusions had been done at our institution. The main
goal of this study was to have an overview of the epidemiological data
regarding the patients receiving erythrocyte and platelet concentrates,
as well as an overview of the number and age of the blood products
transfused.
Methods: Data regarding blood transfusions administered in 2013 was
extracted from the blood bank database, Prosang. Only erythrocyte and
platelet concentrates given at our institution were included in the study.
Blood products issued by the transfusion service, but not transfused
were not included. The different departments were grouped into ten
main groups: Haematology, Emergency room, Gynaecology & Obstet-
rics, Cardiology, Surgery, Internal Medicine, Oncology, Orthopaedics
and Paediatrics. Another group for the rest of the transfusions not fit-
ting in the previous categories was generically named as “other depts.”
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

The data was sorted out by blood product, blood group and age, as well
as for age and gender of the transfused patients.
Results: In 2013, a total of 2 644 patients (51% men and 47% women)
received blood transfusion of either erythrocyte concentrates and/or
platelet concentrates. Approximately 12 000 erythrocyte concentrates
and 2 000 platelet concentrates were transfused. As expected, Surgery
dept. (31.4%), Haematology (15.7%) and Oncology (13.3%) accounted
for the departments with the highest number of transfused erythrocyte
concentrates. The average number of units transfused per patient was 5.3.
The highest number of platelet concentrates was given to haematological
patients (46.3%) and paediatric patients (17%). Approximately 32.5% of
the erythrocyte concentrates were transfused within 17 days, and the
age of half of the transfused units were between 18–29 days. Units of
blood group O RhD-(neg) were the oldest ones to be transfused. Average
age for the transfused patients was 66 years, and most part of the blood
transfusions went to patients aged 64-79 years. Overall, the patients
transfused with erythrocyte concentrates received 4.3 units in average.
Conclusion: The accurate registration, monitoring and evaluation of
the hospital’s blood usage are critical elements in any patient blood
management program. This is the first time such an overview has been
done at our hospital. The results from this study will be used as a model
for monitoring changes in the blood usage at our institution in the future,
as well as a tool for benchmarking with other Norwegian hospitals.
P21
Assessment of the Conformity of Labile Blood Product
Prescription at Charles Nicolle Hospital
R. Znazen, A. Bahloul & S. Guermazi
Laboratory of Haematology and Blood Bank, Charles Nicolle Hospital,
Tunis, Tunisia
Introduction: The step of labile blood products (LBP) prescription is a
crucial link in the transfusion chain. It depends of recommendations,
continuously reformed, and may to reply to norms and numerous regu-
lations, to ensure transfusion security. The aim of our study, is to review
the pertinence of LBP prescriptions and to assess their conformity in
Charles Nicolle Hospital (CNH) of Tunis, as well as, to advance possible
corrective measures for quality assurance.
Methods: Our prospective study was realised in our blood bank of CNH
Tunis, during 3 months (November 2013–January 2014). Data collec-
tion was carried out from 500 LBP prescriptions sent to our blood bank
and corresponding to 371 patients hospitalised. The different parameters
registered on the LBP prescriptions and relating to: patient, LBP, physi-
cian/department, supporting documents and blood samples, were noted
down cards previously prepared.
Results: Fifteen clinical and surgical departments were listed from the
LBP prescriptions studied. But in 2.4% of cases the department was not
mentioned. The age was known for 337 patients among our 371, so in
90.83% of cases (medium age: 44 years, extremes: 1 day–92 years). The
sex ratio was equal to 1.58. Blood group O predominated in 45% of pre-
scriptions. In this work, the total number of parameters studied from the
500 LBP prescriptions was 12 500. Among these parameters, 3612 non
conformities (mistake, omission or abnormality of prescription) were
noted, corresponding to a rate of nonconformity equal to 28.89%, of
which, 5.67% might be considered as, potentially, serious. The distri-
bution of these nonconformities was studied according to their nature:
patient (66.45%), LBP (6.65%), physician/department (15.8%), docu-
ments/blood samples (11.1%).
Conclusion: Our high rate of nonconformity is similar to those found
in literature, not varying for ten years. These results demonstrate that
failures potentially serious, still persist in our transfusion system. But,
the LBP considered as “drugs” treating numerous pathologies, must
provide for patient effective treatment compatible with the maximum
of security. So, it is urgent to improve LBP prescription quality through
strengthening our haemovigilance system via continuous assessment
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 21
and constitution of multidisciplinary committee suggesting corrective
measures and recommendations necessary to the improvement of our
“transfusion practices”: continuous medical and paramedical continuing
education, computerisation, continuous control and updating.
P22
Platelet Consumption, Indications, Transfusion Triggers
and Response to Treatment in Hospital Wards in Tehran
M. Zadsar1 , M. Nasserani Pour2 , A. Chegini3 , A. Lotfi4
& M. Mojtabavi Naeeni5
1 High Institute of Education and Research on Transfusion Medicine,
Research Centre, Tehran, Iran
Introduction: Thrombocytopenia is one of the most prevalent compli-
cations in ICU admitted patients that could increase the risk of haemor-
rhage, duration of ICU stay, morbidity and mortality. Platelet transfusion
is used to prevent or treat haemorrhagic conditions. Indications, triggers
and response to platelet transfusion in ICU of two hospitals in Tehran
were studied.
Methods: In the descriptive study, 380 thrombocytopenic ICU admitted
adult patients were enrolled. Indications, triggers, response to platelet
transfusion (CCI), type of component, prophylactic or therapeutic trans-
fusion and No. of transfused units were studied.
Results: Among 380 patients, 124 (32.2%) got platelet transfusion, 64
(51.6%) were prophylactic and remaining were therapeutic.30 (24.2%)
used the aphaeresis platelet and remaining were used RDP homologous
PC. Mean of transfused units was found as 4.5 and in 58 (46.8%) of
cases the non-immunologic causes of refractoriness were found. Trig-
gers of prophylactic platelet transfusion 33 ± 4 × 109 /L and therapeu-
tic platelet transfusion 58 ± 8 × 109 /L have had significant difference (P
value = 0.04).
Triggers of transfusion aphaeresis19 × 109 /L compared to RDP homol-
ogous PC 55 × 109 /L was shown significant differences (P = 0.01). The
mean of 1st hour and 20th hour CCI were 3700 and 3300, respectively.
Conclusion: Almost half of transfusions in ICU were prophylactic. More
than half of ICU patients which got platelet transfusion are unable to
build a successful increment after a single transfusion.
P23
Decisive Factors about Transfusing Standard or High Doses
of Platelets in Daily Clinical Practice
S. Montesdeoca1 , M. López2 , A. Senin1 , M. Ferraro1 , E. Johansson1
& C. Besses1
1 Department of Clinical Haematology, 2 Blood Transfusion Service,
Hospital del Mar, Barcelona, Spain
Introduction: Platelet transfusions are an essential procedure in the
daily activity of a Haematology Department. The dose of platelets in
the setting of prophylactic transfusions is still a controversial issue.
According to the few studies available , the use of standard (equivalent
to 1 platelet pool) versus high doses (equivalent to 2 platelet pools) of
platelets led to a decreased number of platelets transfused per patient,
but also to an increased number of transfusions with no effect on the
incidence of bleeding.
Objective: To investigate the variables influencing the decision-making
process of clinical haematologists regarding standard (single pool) or
high doses (two pools) of prophylactic platelets.
Methods: An observational study collecting data from all the electronic
platelet transfusion requests from the Haematology Department in the
2013–2014 period was performed. Transfusion policy was assessed
before and after an active educational intervention focused on the low
impact of high versus standard prophylactic platelet dosage in the num-
ber of clinical bleeding events. Every request was considered as an
independent event. We collected dosage, indication (prophylactic or
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
22 Abstracts of the 16th Annual NATA Symposium
before an invasive procedure), diagnosis (acute leukaemia, myelodyspla-
sia, and others), patient’s weight, and platelet count before the transfu-
sion. Adverse transfusion reactions were registered as usual.
Results: In 2013, 725 platelet pools were transfused in the Department,
corresponding to 389 platelet requests where 183 (47%) included high
doses (two platelet pools). In 2014, 413 platelet pools were transfused,
corresponding to 248 requests where only 63 of them (25%) selected
high doses. The decision to transfuse high platelet doses was based
on the patient’s weight (p < 0.0001) but other factors like the platelet
count <10 000/μL (p < 0.001), the diagnosis (p < 0.04) and the indica-
tion (p < 0.039) reached also statistical significance. The year, 2014 versus
2013, appeared as a protective factor (p < 0.0001) against the administra-
tion of high doses of platelets. In 2013 and 2014 the incidence of platelet
reactions was 1.9%, with 2 severe adverse reactions, and 1.6% and no
severe reactions, respectively. The incidence of bleeding events was sim-
ilar in both groups.
Conclusion: 1. Educational intervention may influence platelet prescrip-
tions. 2. The use of more prophylactic standard doses in 2014 did not
increase the total number of platelet transfusions and the appearance of
clinical bleeding. 3. Doctors’ selection of standard or double, high platelet
doses is based on several factors and not only on the patient’s weight.
4. Clinical sessions and updates really have impact and improvement
in the daily clinical practice. 5. The reduction in the number of platelet
transfusions has lowered the incidence of transfusion adverse reactions.
Platelets are associated with the highest occurrence of transfusion reac-
tions. We reduced the incidence of undesired effects to our patients.
P24
The Reasons for Blood Transfusion Overuse
R. Rahav, C. Suriu, L. Akria, M. Barhoum & A. Braester
Haematology Institute, Galilee Medical Centre, Nahariya, Israel
Introduction: A significant percentage of RBC transfusions have been
identified to be inappropriately overused. Recent worldwide studies
demonstrate a restrictive blood management (RBM) approach to be
either superior or not inferior to a liberal approach in improving clinical
outcome, and reducing RBC transfusion use. In this study, we assessed
the potential reasons for the overuse of RBC transfusion by investigating
the knowledge of transfusion medicine among physicians from different
departments in the Galilee Medical Centre.
Methods: This was a descriptive, cross-sectional study. Information
was collected via an anonymous questionnaire. Dependent variable: the
knowledge. The main dependent variable is the general knowledge. In
addition, knowledge was examined in two specific aspects: 1) familiarity
with the RBM discipline and 2) knowledge regarding indications for RBC
transfusion. Independent variables: field of specialty, seniority and place
of graduation of the participating physicians.
Results: There is a lack of general knowledge and basic physiology in
the field of transfusion medicine among physicians, which is the princi-
pal cause of RBC overuse. The physician’s field of specialty and seniority
influences the knowledge of transfusion medicine, while place of medical
studies does not. The mean score in knowledge of general and basic phys-
iology among the study population was 47.4 on a 0–100 scale. Familiar-
ity with the discipline of RBM was also evaluated and the mean score
of the study population was 48.9%. The mean scores of questions in the
RBM discipline were calculated and compared on a 0-100 scale accord-
ing to subgroups: field of specialty, seniority and place of medical stud-
ies. Comparison between fields of specialty showed internal medicine
departments had a higher mean score of knowledge regarding familiarity
with the RBM discipline than did surgical departments (p = 0.003). Sim-
ilarly, comparison of physician’s seniority showed that specialists scored
higher than residents (p = 0.0025). Comparison of the place of medi-
cal studies (Israel vs. non Israel graduates) – medical schools showed no
major difference between the groups and a statistical significance was not
found. Knowledge regarding indications for transfusion was evaluated by
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
questions that were further divided into "surgical field indications" and
"internal medicine field indications". A high level of heterogeneity was
found among the answers. The calculated mean score of the study pop-
ulation regarding indications for transfusion was 42 on a 0–100 scale.
A statistical trend was found in the field of specialty and seniority: a
better knowledge of indications for transfusion was found among inter-
nal medicine physicians than surgeons (p = 0.068) and among specialists
over residents (p = 0.078). Comparison of the place of medical studies
showed no clinical or statistical differences.
Discussion and Conclusions: 1. There is a lack of general and basic
knowledge of the physiology of transfusion medicine, which leads to
RBC overuse. Conducting similar investigations in other Israeli hospitals
would be beneficial. Continuing education that includes repetition of
the basic physiologic reasons for RBC transfusion should be considered.
2. Individual background such as field of specialty and seniority, but
not place of medical studies has an influence on the physician’s general
knowledge of transfusion medicine.
P25
Two-unit Transfusion Practice
C. Donohue, A. Li & S. Mallett
Royal Free NHS Foundation Trust, London, UK
Introduction: Patient blood management (PBM) is the rationalised use
of a potentially hazardous, scarce and costly resource. PBM is based on
three pillars: optimisation of erythropoiesis, minimisation of blood loss
and tolerance to anaemia. Restrictive transfusion triggers, targets and
policies comprise a central component of PBM. We suspected that a cul-
ture of giving 2 units of red blood cells (RBC) rather than each and every
unit representing an independent clinical decision, was still ingrained
in clinical practice. In other centres, as PBM programs and single unit
transfusion policies have been implemented, 2-unit transfusions have
declined. We wanted to analyse our transfusion practice as a starting
point for implementation of a single unit transfusion policy.
Methods: Over a 1 month period all adult patients who received 2 units
of RBC as a single episode were identified at blood bank and patient
notes, prescription charts and electronic laboratory records interrogated
to identify transfusion triggers and peri-transfusion haemoglobin (Hb)
levels. Haematology, renal and intensive care patients were excluded
from analysis. Data were analysed in Excel.
Results: 58 2-unit RBC transfusions were administered over the 1 month
study period. Median age was 69.8 years with a female to male and surgi-
cal to medical preponderance (60% vs. 40% and 65.5% vs. 34.5%, respec-
tively). 10% had documented ischaemic heart disease (IHD). The most
commonly represented specialty was orthopaedics, followed by hepa-
tobiliary surgery. 95% of patients were transfused on the ward and 3
in recovery or endoscopy. The most commonly documented indication
for transfusion was ‘anaemia’ in 37/58 cases. Only 1 patient had clin-
ically significant active bleeding though 15 others had some evidence
of blood loss. Nine had symptoms associated with low Hb and 8 had
minor haemodynamic changes. In 15 cases no indication for transfusion
was documented. Mean pre-transfusion Hb (± SD) was 77 g/L (±10.2)
and 98 g/L (±11.1) post 2-unit transfusion. In 20/58 (38%) cases, post
transfusion Hb was >100 g/L indicating a potentially unnecessary 2nd
unit of blood and exposure to the dose-dependent risks of transfusion.
24/58 had post-transfusion Hb >90 g/L which may represent an over-
transfused group in the context of more restrictive transfusion targets.
When patients with post-transfusion Hb >100 g/L were reviewed, they
had similar demographic characteristics and prevalence of IHD com-
pared with the group as a whole.
Conclusions: In this short snapshot analysis of 2-unit transfusion
practice we have identified between 38–76% of stable ward patients
with excessive post-transfusion haemoglobin levels. There is scope for
improved rationalisation of RBC with introduction of a single unit trans-
fusion policy in conjunction with more restrictive transfusion targets.
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

P26
Variance in Transfusion Practice in the Era of Patient Blood
Management – a UK Multicentre Collaborative Study
M. S. Brar1 , L. Ogilvie2 , T. Richards3 & A. A Klein2 , on behalf of the
Association of Cardiothoracic Anaesthetists (ACTA)
1 London School of Hygiene and Tropical Medicine, London, UK;
2 Papworth Hospital, Cambridge, UK; 3 University College Hospital,
London, UK
Contributors: R. P. Alston (Royal Infirmary of Edinburgh, Scotland); H.
Pauli (Freeman Hospital, Newcastle); G. Hallward (St Thomas’ Hospital,
London), A. Vijayan (Castle Hill Hospital, Hull); A. Pai (Essex Cardio-
thoracic Centre, Basildon, Essex); C. Evans (University Hospital of Wales,
Cardiff); D. Krahne (Kings’ College Hospital, London); D. Glasgow (Royal
Victoria Hospital, Belfast, N. Ireland); P. Fernandez Jimenez (Manchester
Royal Infirmary, Manchester); S. Agarwal (Liverpool Heart and Chest Cen-
tre, Liverpool); A. Kelleher (Royal Brompton Hospital, London); A. Cohen
(Bristol Heart Institute, Bristol)
Introduction: Patient blood management is now mandatory in UK
hospitals. However, risk factors for transfusion and variance of practice
in UK cardiac surgical centres are not known.
Methods: All adult patients undergoing cardiac surgery at 12 UK centres
from 2010 through 2012, inclusive, were studied. A complete case anal-
ysis was performed, and centres were compared using student t-test or
chi square test, as appropriate. A multivariable logistic regression model,
adjusted for clustering by centre (fixed effect), was constructed to predict
in-hospital death.
Results: A total of 23 800 adult patients underwent cardiac surgery at
one of the 12 centres during the 3-year study period. Variation was
observed in centre-specific rates of transfusion, ranging from 31% to
60% (p < 0.001); the number of units of blood transfused also varied
(median units 2-4, p < 0.001). Mortality also varied between centres,
with the odds ratio (OR) of in-hospital death varying from 0.24 to
2.39 (p < 0.001), however confidence intervals were wide when exam-
ining individual centres and after controlling for independent predictors
(centre, logistic EuroSCORE, cardiopulmonary bypass time, creatinine,
hypertension, operation time, transfusion, and preoperative anaemia).
The model demonstrated adequate calibration and a high level of dis-
crimination.
Conclusion: UK centres varied greatly in rates of transfusion. Variance
in blood transfusion practice between centres may be explained by
patient and operative factors not accounted for in this study. However,
the high variance between centres strongly suggests institutional practice
is an important factor that determines the rate of blood transfusion.
P27
Evaluation of Perioperative Crossmatch and Transfusion
Practices
A. Fleischer, M. Wittmann, J. Hoch, O. Boehm & G. Baumgarten
Department of Anaesthesiology and Intensive Care, University Hospital
Bonn, Bonn, Germany
Introduction: Crossmatch-to-transfusion (CT) ratio is a valuable indi-
cator for the quality of an institution’s blood ordering practices. A high
CT ratio indicates failure to accurately anticipate the need of transfusion:
blood products in “crossmatched” state are reserved for the individual
patient, thus a high CT ratio necessitates a higher number of available
blood products and leads to increased aging and thereby discarding of
blood products. Previously at our hospital it was only possible to deter-
mine CT ratios at organisational levels (department/ward). Our goal was
to develop a tool enabling the evaluation of perioperative blood order-
ing and transfusion practices based on the surgical procedure performed
and the patients’ preoperative haemoglobin level.
Methods: We built a relational database containing anonymised data for
all in-patients admitted to our hospital in 2012 and 2013, including their
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 23
first determined haemoglobin level, any surgical procedure performed
on these patients, and all ordered and transfused units of packed red
blood cells (PRBC). A software was created to analyse this database for
any given procedure, outputting preoperative blood ordering and peri-
operative transfusions for this specific procedure while considering a
sub-group of patients with preoperative anaemia. The results are dis-
played as raw data to process in statistics packages, but also pre-analysed
in easy to read tables and graphs.
Results: Preoperative anaemia is more common in our hospital than
published data would suggest; CT ratios for anaemic patients were much
better than for non-anaemic patients, indicating a general problem in
risk stratification. We were also able to show that for several procedures,
clinicians ordered significantly more PRBCs than current guidelines
advised, pointing to a lack of adoption of existing standards.
Conclusion: Using this software, we are able to pinpoint surgical proce-
dures with problematic CT ratios and provide empirical data to aid in
the development of new preoperative Blood Ordering Schedules sensi-
tive to preoperative anaemia. Besides having a direct economic impact,
this will aid in improving quality of care for our patients by reducing
ageing of blood products.
P28
Pennine Acute Trust’s Initiatives on Blood Wastage
A. Allameddine, H. Morris, D. Curley, S. Flynn, M. Heaton & H. Jenkins
The Pennine Acute Trust, Manchester, UK
Introduction: Blood components are precious and of limited resources.
Wastage is considered a massive economic burden to healthcare and
often is inevitable, particularly for fresh products with short expiry dates;
however, a proportion of this is neither inevitable nor appropriate.
Description: At Pennine Acute Trust the cost of blood products is over
£3 million/year with wastage level around 3.8%. Internal audits revealed
that wastage is mainly due to issues related to stock levels, storage and
transport, lack of awareness and poor compliance and communication
among clinicians and lab staff.
The Hospital Transfusion Team produced a strategic plan to address
wastage and the following initiatives were introduced:
• Reduction and regular monitoring of stock levels
• Sharing blood between different hospital sites, especially platelets
• Issuing O Rh Negative ‘paedipacks’ instead of ABO and limiting
number of packs issued based on gestational age
• Raising awareness on blood cost and wastage with regular com-
munication and feed back to clinicians and managers
Results: Comparison was made of six months period between November
2012–April 2013 and November 2013–April 2014, after the implemen-
tation of these initiatives.
RBC RBC Cost Wastage/
Adult Paediatric PLT FFP (£) total blood
Nov 2012 – Apr 187 224 77 157 53 478 3.85%
2013
Nov 2013 – Apr 96 84 30 133 29 102 2.36%
2014
Reduction –49% –63% –61% –15% –46% –39%
Data revealed significant reduction in blood wastage since these ini-
tiatives were introduced. The most significant reduction was seen in
Women’s & Children’s division with wastage reduced by 66% from
£13,603 to £ 4,025, followed by the Laboratory wastage reduced by 38%
from £19.600 to £12.192.
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
24 Abstracts of the 16th Annual NATA Symposium

Conclusions: Raising awareness and implementing initiatives to prevent P30

blood wastage resulted in positive impact on our health care system with
reduction in cost of 46%, equivalent to 2.36% of the total blood cost and
Improving Orthopaedic Blood Transfusion Practice in a UK
saving £25 000 in 6 months. Teaching Hospital
J. W. Lim1 , Z. Y. Tew1 , L. R. Johnston2 & C. Connolly3
1 MedicalStudents; 2 Audit Department - Department of Orthopaedic &
P29 Trauma Surgery; 3 Department of Anaesthesia, Ninewells Hospital
and Medical School, Dundee, Scotland, UK
Project for Quality Improvement 2014: “Measures
to Reduce Blood Component Expiration Rate of at Huesca Introduction: In our institution, orthopaedics is the surgical specialty
Sector” – Preliminary Data which uses the highest percentage of donated blood. In 2008, an audit of
blood use revealed a 40% perioperative transfusion rate in orthopaedics
J. A. Garcia-Erce1,2 , B. Menendez3 , S. Gómez3 , M. Borrel3 ,
for joint replacements and trauma, excluding polytrauma, and poor
M. Cebollero3 , A. Lezaun3 & J. J. Marco3
1 GIEMSA-AWGE, Spain; 2 IdiPAZ49, Spain; 3 Haematology & documentation of the reason for transfusion. In the interim, we delivered
Transfusion Service, Hospital San Jorge, Huesca, Spain education on better blood transfusion in orthopaedics and this paper
is the result of a re-audit of transfusion practice in orthopaedics over 2
Aim: To present the preliminary health care and economic data from months in 2014.
Project for Quality Improvement 2014: “Measures to reduce blood com- Methods: We prospectively reviewed all orthopaedic cases between
ponent expiration rate of at Huesca sector”. Starting in 2014 the new April and June 2014 in Ninewells Hospital. Patients who received
protocol includes: progressive replacement of crossmatching and save by blood transfusion were identified by “account for blood” data and the
type & screening, optimisation of sample validation, "restrictive" transfu- orthopaedic audit department. We examined preoperative haemoglobin
sion criteria, single-unit transfusion, and management of perioperative (Hb) levels, discharge Hb levels, pre-transfusion and post-transfusion
anaemia. Hb levels, co-morbidities, ASA score, documentation of indication for
Material and Methods: Data on units (U) of blood components (BC) transfusion and consent.
transfused (January-December 2010–2014) were obtained from Blood Results: 524 procedures were performed on 500 patients. 37 patients
and Tissues Bank of Aragon (BTBA) (NetBank Gold, IZASA), includ- received a total of 49 blood transfusions indicating a transfusion rate
ing packed red blood cell (PRBC), inactivated fresh frozen plasma of 7.4%. The average age of the transfused cohort was 73 years-old and
(FFP) and platelet concentrates (PLT). Transfusion compatibility tests average BMI was 24.5 kg/m2 . Patients undergoing hip procedures were
included: blood grouping (BG), irregular antibodies screening (IAS) the most likely to require blood transfusion: 9 total hip replacements, 4
and cross-matching (CM). Data on hospitalisations, stays, Emergency revision hip procedures, 4 hemiarthroplasties, 5 compression hip screws.
Department activity and surgical activity were obtained from the hos- 49% of patients were ASA 3. In the transfused cohort the average preop-
pital activity management program. Economic data were obtained from erative Hb was 115 g/L, pre-transfusion Hb was 87 g/L, post-transfusion
the hospital acquisition management program. Official public BC costs Hb was 105 g/L, and final Hb was 110 g/L. In the non-transfused cohort
were obtained from health authority of Aragon Government (BOA, July the average preoperative Hb was 132 g/L and final Hb was 111 g/L. These
29th 2013, regulating of the public prices of BTBA). results are consistent with previous evidence that optimisation of preop-
Results: As shown in Table 1, compared to 2010, the overall BC transfu- erative Hb reduces the need for blood transfusion. 43/49 (88%) trans-
sion was reduced by 1198 U (38%) in 2014, as did the number of trans- fused patients had a post-transfusion Hb ≥90 g/L, which is not consistent
fused patients (724 vs. 570; –21%) and total units per patient (4.3 vs. 3.4; with a restrictive strategy but could be considered as over-transfusion.
–21%). BG, IAS and especially CM were also significantly reduced with The reason for transfusion was documented in the medical notes in 80%
respect to 2010. Regarding costs, the reduction in transfusion activity of cases – 65% were for low Hb and 14% were for blood loss. There was
resulted in estimated savings in BC acquisition of €170 122 with respect documentation of the discussion with the patient in only 29% of cases
to 2010, and €171 199 with respect to 2012. Savings in compatibility test- transfused. 71% of those transfused received 2 units of blood, irrespec-
ing amounted €71 941 and €53 903, respectively. Thus, overall estimated tive of their pre-transfusion Hb.
savings have been €242 063 and €225 103, respectively. Conclusion: This audit has shown a significant improvement in the over-
all transfusion rate in orthopaedics with a decrease from 40% to 7.4%
Table 1. since 2008. However, we have also found that preoperative optimisa-
tion of Hb with iron is not taking place effectively; the transfusion target
January–December 2010 2011 2012 2013 2014 is higher than the evidence-based restrictive target1 ; the culture is to
transfuse 2 units and then reassess. We have presented this data to our
PRBC (units) 2725 2688 2817 2398 1761 orthopaedic and anaesthetic departments. We have devised a periopera-
FFP (units) 216 190 183 89 116 tive anaemia pathway, which includes the single unit policy with a traffic
PLT (units) 203 120 182 102 64 light rating system. We plan to introduce this policy in January 2015,
Autologous (units) 0 0 6 2 5 re-audit in February and March 2015 with preliminary results available
Total BC (units) 3144 2998 3188 2591 1946 in April 2015.
Transfused Patients (n) 724 669 702 680 570
BG and Rh (n) 2531 2438 2366 2315 1984 REFERENCE
IAS (n) 2494 2424 2338 2294 1958 Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfu-
CM (n) 5688 5471 5261 5056 3762 sion in high-risk patients after hip surgery. N Engl J Med 2011;365:
2453-62.

Conclusion: These preliminary data of the first year of the implementa-

tion of a more rational, individualised and evidence-based use of BC, as
recommended by the patient blood management paradigm, can be safe,
effective and beneficial for patients, from both healthcare provider and
societal perspectives.

Transfusion Medicine, 2015, 25, Suppl. 1, 13–54 © 2015 The Authors

Transfusion Medicine © 2015 British Blood Transfusion Society

P31
Impact of Individual Physician Blood Reports and “1 vs. 2
Unit” Metric to Lower Red Blood Cell Transfusions
N. Tabesh1 , J. DeLisle1 , J. Shelby2 , D. Oseland1 & K. E. Puca1
1 BloodCenter of Wisconsin, Milwaukee, WI, USA; 2 Wheaton Franciscan
Healthcare-All Saints, Racine, WI, USA
Introduction: Many blood transfusions are considered inappropriate,
providing either no benefit or a heightened risk of complications. Strong
evidence exists of a dose-dependent risk for adverse patient outcomes
associated with blood transfusion. Ordering of 2 unit red blood cell
(RBC) transfusions by many physicians has become standard practice
not based on evidence. Recent transfusion guidelines published in the US
support a single-unit RBC transfusion practice – give one unit and then
reassess. To promote evidence based transfusion practice we tracked
single-unit transfusion orders and provided individual physician feed-
back on their blood usage to assess the effect on overall RBC usage.
Methods: Beginning in late 2012 blood utilisation data has been col-
lected and reported using a proprietary analytics and reporting software
for one hospital in a healthcare system. Quarterly reports on overall RBC
transfusions and percent of 1-unit and 2-unit RBC orders were provided
to Chairs of each physician department for discussion at department
meetings. Starting in Jul-Sep 2013 Hospitalist physicians were piloted
for each to receive their own individual reports since as a whole this spe-
cialty ordered 30% or more of total RBC inpatient transfusions. These
individualised physician reports included the hospitalist’s own usage on
overall RBC transfusions and percent 1-unit, 2-unit orders compared to
other hospitalists’ data which was blinded.
Results: RBC transfusions per quarter from Oct-Dec 2012 to Jul-Sep
2014 dropped by 18% (1178 vs. 962 units; p = 0.08). RBC transfusions
per quarter by Hospitalists over the same time period declined by 29%
(399 vs. 282 units; p = 0.006) compared to 13% decline in RBC transfu-
sions per quarter by non-Hospitalists (779 vs. 680 units; p = 0.25). After
regular individualised physician reporting to the Hospitalists, percent of
2 unit RBC orders declined by 53.3% (p = 0.003). Prior to individualised
reporting of “1 vs. 2 unit” metric RBC usage by Hospitalists averaged
420 units per quarter; whereas RBC usage averaged 272 units per quarter
after regular reporting of the metric (p = 0.058).
Conclusion: Eighteen percent lower overall RBC usage was seen with
regular reporting of blood utilisation data. Individualised physician
reporting accelerated this improvement. Tracking an indicator of “1 vs. 2
unit” transfusion orders resulted in a trend toward better RBC utilisation
as well as improved utilisation of 1 unit transfusion orders.
P32
100% Compliance to Blood Transfusion Policy Reduces
the Use of Blood Significantly
A. van Gammeren, M. Haneveer, M. Huisman-Ebskamp & R.
Slappendel
Amphia Hospital, Clinical Chemistry and Hematology, Breda, The
Netherlands
Background: A restricted blood transfusion policy is generally beneficial
for donor and patient and for health care costs. The Amphia Hospital
developed and implemented a checklist (see figure) as part of blood
product request procedure to obtain optimal and appropriate use of
blood products, in accordance with the recently updated national blood
transfusion guideline and local agreements.
Methods: The Amphia Hospital blood transfusion committee intro-
duced a new and stricter policy for blood requests for haemodynamic
stable patients in order to prevent over-transfusion and to reduce costs.
Physicians are obliged to complete a checklist with pre-transfusion
patient information before blood units can be requested. The checklist
determines the maximum units of blood that can be requested. Labora-
tory coworkers control the checklist before approval of the transfusion.
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 25
Checklist blood transfusion for haemodynamic stable patients
Younger than 60 year
Hb <4.0 mmol/L (6.4 g/dL) = 1 unit
Hb <3.5 mmol/L (5.9 g/dL) = 2 units
Older than 60 year
Hb <5.0 mmol/L (8.0 g/dL) = 1 unit
Hb <4.5 mmol/L (7.2 g/dL) = 2 units
Patients with cardiac, pulmonary or cerebrovascular disease
Hb <5.5 mmol/L (8.8 g/dL) = 1 unit
Hb <5.0 mmol/L (8.0 g/dL) = 2 units
Results: The new protocol has led to 100% compliance to the stricter
and newly introduced transfusion protocol. After introduction of the
new request policy, the hospital transfusion ratio declined from 0.26
to 0.23 red blood cell transfusions per patient, which equals 11.5%
reduction of red blood cell units in haemodynamic stable patients. The
average pre-transfusion haemoglobin level declined with 0.21 mmol/L
(0.34 g/dL) from 5.04 (8.06 g/dL) to 4.83 mmol/L (7.73 g/dL).
Conclusion: By the implementation of a simple checklist, our hospi-
tal realised a significant reduction of local transfusions. The beneficial
effects potential in terms of reduced costs, decreased load on donors and
improved patients healthcare at a national or world-wide scale is obvious.
The practical approach to use a simple checklist as part of the transfusion
request form can be adapted to other national blood transfusion guide-
lines as well.
P33
The Impact of Single-unit Transfusion Policy on Pennine
Acute Trust Blood Usage
A. Allameddine, M. Heaton, H. Jenkins, S. Andrews, B. Sedman, C.
Porada, & H. Morris
The Pennine Acute Trust, Manchester, UK
Introduction: Each year around 2.5 million units of blood products
are transfused in the UK and around 20 000 units are transfused at
Pennine Acute Trust (PAT). Historically and despite a lack of studies,
most guidelines recommend double-unit transfusions, while only a few,
including more recent guidelines allow single-unit RBC transfusions, in
the absence of active bleeding. A restrictive transfusion trigger is one
of the most effective measures to reduce blood usage and the potential
associated risks, with major benefit for the health care system.
Description: Recent data suggest that a single-unit transfusion is safe
and can considerably reduce blood usage, as confirmed by a study by
Berger et al.1 where a change from double to single-unit transfusion pol-
icy showed to be safe and resulted in reduction of 25% of RBC transfu-
sion requirements in a population with haemato-oncological disorders.
At PAT, the Hospital Transfusion Team introduced the single-unit trans-
fusion policy in January 2014 and asked clinicians to consider prescrib-
ing single-unit RBC transfusion for non-bleeding patients.
Results: Provisional data are encouraging and show significant impact
on the whole blood usage within PAT, across all divisions, particularly in
the haematology and the Acute Medical wards. The analysis showed that
in the haematology inpatient ward, the first 4 months of 2014 showed
22% compliance to single unit policy compared to 4.3% in the same
period of 2013 with 15% reduction in blood usage, equivalent to 95
units. The same is seen in the Acute Medical wards where the compliance
was 22% and the saving of RBC units was 24%. Nevertheless, in both
surgical and haematology outpatients, where the compliance to single
unit policy was minor, between 12-14.5%, the saving was 8 and 6%,
respectively.
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
26 Abstracts of the 16th Annual NATA Symposium

Methods: From December 2013 to March 2014, the acquisition of

knowledge in TM was evaluated through a questionnaire consisting of 20
RBC Units RBC Units multiple choice items divided into 3 sections: Section I (4 items regarding
2013 2014 Saving regulations, blood donation, and blood processing), Section II (10 items
Period Jan-Apr (% single unit) (% single unit) Units regarding transfusion practice and transfusion alternatives), and Section
III (6 items on adverse effects of transfusion). The evaluation was per-
Surgical Wards 552 (2.1%) 507 (12%) 45 (8%) formed at the beginning of the one month stay in the ED, followed by a
Acute Medical Wards 252 (2.7%) 191 (17.7%) 61 (24%) clinical update session consisting of an interactive educational workshop
Haematology inpatient 633 (4.6%) 538 (22%) 95 (15%) where real medical cases were presented and discussed. The participants
Haematology outpatient 489 (7.9%) 459 (14.5%) 30 (6%) were also involved in supervised clinical care of patients during their
Total 1926 (4.3%) 1695 (16.6%) 231 (12%) ED stay. The evaluation was performed again at the end of the forma-
tive period. Each positive answer was scored with one point, and initial
and final evaluation scores were compared.
Results: A total of 39 individuals participated in the evaluation (16
last year medical students and 23 first year post-graduate trainees). The
Conclusion: Implementing a single-unit transfusion policy would save scores for the first and second evaluations, both overall and by sections,
up to 25% of red blood cell units, depending on the level of compliance are depicted in Figure 1. As reflected by the higher scores in all sections
and thereby, reduces the risks associated with allogeneic blood transfu- of the questionnaire in the second evaluation, a moderate but significant
sions. improvement in TM knowledge was observed.

REFERENCE 15 First evaluation

1. Berger MD, Gerber B, Arn K, Senn O, Schanz U, Stussi G. Signifi- * Second evaluation
cant reduction of red blood cell transfusion requirements by changing
from a double-unit to a single-unit transfusion policy in patients receiv- 10

Score
ing intensive chemotherapy or stem cell transplantation. Haematologica
2012;97:116-22.
*
5 *
P34
*
Evaluation of an Educational Intervention in Transfusion
0
Medicine for Medical Students and Postgraduate Trainees Overall Section I Section II Section III
N. Cancellere1 ,S. Fabra1 ,
A. M. Martinez-Virto1 ,
S. Gómez-Ramirez2 ,
Figure 1. Scores for the first and second evaluation of TM knowledge
J. A. García-Erce3 & M. Quintana-Díaz1
1 Emergency Department, University Hospital La Paz, Madrid, Spain; (*P < 0.05)
2 Transfusion Medicine, School of Medicine, University of Málaga, Spain;
Conclusion: A formative intervention in TM, through interactive edu-
3 Haematology, General Hospital San Jorge, Huesca, Spain
cational workshops and everyday clinical patient care, allows the acqui-
Objective: Knowledge of transfusion medicine (TM) is central to every- sition of valuable knowledge on a medical discipline which affects
day practice in several medical specialties. However, teaching activities in most medical specialties, but is unsatisfactorily taught at most medical
TM at medical schools are generally scant and incomplete. Thus, transfu- schools. In TM, the provision of early formation and continued medical
sion practice of post-graduate trainees is more influenced by the opinions education to medical students and postgraduate trainees will most prob-
of their senior colleagues and supervisors than by evidence-based guide- ably result in an improved use of both blood components and transfusion
lines. This study was aimed to evaluate the knowledge in TM acquired by alternatives.
last year medical students and first year post-graduate trainees during
their stay at the hospital Emergency Department.

Transfusion Medicine, 2015, 25, Suppl. 1, 13–54 © 2015 The Authors

Transfusion Medicine © 2015 British Blood Transfusion Society

BLOOD CONSERVATION STRATEGIES/AUTOLOGOUS
TRANSFUSION
P35
“Patient Blood Management Italy”: the Italian Pathway
towards Interdisciplinary and Multimodal Blood
Conservation Strategies
G. M. Liumbruno, S. Vaglio, G. Marano, S. Pupella & G. Grazzini
Italian National Blood Centre, National Institute of Health, Rome, Italy
Introduction: In 2010, patient blood management (PBM) was embraced
by the World Health Organization (WHO), which identified the need for
PBM and, by issuing WHO resolution WHA63.12, urged all its member
states to implement various transfusion-related strategies including PBM
with its three-pillar approach. Currently, the implementation of PBM in
Europe, except for the Netherlands (where hospitals began to implement
it more than 10 years ago), is limited.
Methods: In Italy, the National Blood Centre (NBC), the competent
authority entrusted with the coordination of the blood system, included
the implementation of a PBM programme among the objectives of
the 2012 national plan for blood and blood product self-sufficiency.
In the first semester of 2013 a multidisciplinary PBM working group,
coordinated by the NBC, was set up with the aim of implementing PBM
strategies in elective orthopaedic surgery (EOS), to begin with.
Results: In 2014, the national “Patient Blood Management Italy” project
was officially launched (Figure 1). The PBM working group, composed
of experts in transfusion medicine, anaesthesiology, haemostasis and
thrombosis, orthopaedic surgery, and the management of health facil-
ities, designated by the relevant Scientific Societies, produced guide-
lines on the implementation of PBM in EOS. The NBC identified a list
of minimal and maximal data set [demographic details of all patients
including transfused and non-transfused; data on blood products; basic
data (transfusion/indications); indicators of the PBM three pillars con-
cept; epidemiology data; outcome of transfusion recipients and con-
trols; economic data] to be used by the hospitals for data collection
and PBM benchmarking. In December 2014, the PBM implementation
project was initially launched in two large teaching Hospitals (the Rizzoli
Orthopaedic Institute of Bologna and the 1st University Department of
Orthopaedics and Traumatology of Pisa), which will also deal with the
most challenging aspect of PBM, namely the implementation of preop-
erative treatment of anaemia.
Fig. 1. Logo of the “Patient Blood Management Italy” project
Conclusion: Many EU countries currently endorse PBM or similar
concepts. National blood competent authorities are called to hold a key
role in promoting, implementing and auditing PBM programmes in
order to comply with the WHO resolution WHA63.12.
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 27
P36
Are Hospitals Implementing a Patient Blood Management
Programme?
P. Castelló, V. Guilló, M. Ortega, S. Arango, A. Blanco & A. Peral
Puerta de Hierro Hospital of Majadahonda, Madrid, Spain
Introduction: Day by day there is more evidence that restricting blood
transfusions improves outcomes, inventory troubles and costs. This have
promoted recommendations for its restriction as well as a growing
interest in alternatives, generally known as patient blood management
(PBM). Institution-based initiatives are still variable and inconsistent
in this aspect. We analysed the implementation of a Patient Blood
Management Programme in all the Anaesthesia Departments of the third
level hospitals in Madrid, Spain.
Materials and Methods: Data was collected from the Anaesthesia
Departments from the eight tertiary hospitals in Madrid (Puerta de
Hierro Majadahonda, La Paz, Ramón y Cajal, La Princesa, Clínico de San
Carlos, Fundación Jiménez Díaz, 12 de Octubre and Gregorio Marañón)
using a brief 17-item questionnaire (one questionnaire per hospital) to
study the three different pillars of PBM.
Results and Discussion: We can divide PBM in three pillars. The first
pillar is aimed to optimise haemopoiesis. Preoperative anaemia a con-
traindication for the surgery in 7 of 8 tertiary hospitals in Madrid and
treated those cases with IV iron, erythropoietin and vitamins to opti-
mise preoperative haemoglobin levels. 5 hospitals considered patients
unfit for scheduled surgery when haemoglobin values were below 13
and 12 mg/dl in men and women respectively. 2 centres only do if below
10 mg/dL for both sexes. 87.5% of Anaesthesia Departments have imple-
mented a protocol for management of preoperative anaemia. The second
one is to minimise blood loss and bleeding. Are they using tranexamic
acid? 5 out of 8 centres use it in a standardised way in cardiac and
orthopaedic surgery. Only 3 out of 8 hospitals have an autologous blood
donation programme in selected cases. Postoperative filtered blood sal-
vage is used in 6 out of 8 centres. 6 departments have a POC bedside
coagulation device (ROTEM). However, although available, only two of
them actually guide blood product transfusion by ROTEM in cardiac
surgery. The third pillar is directed to optimising tolerance of anaemia
and using a restrictive transfusion trigger. Perioperative transfusion trig-
ger varies between 7 (50% of the tertiary hospitals) and 8 (50% of the
tertiary hospitals) and only 1 of the 8 hospitals still transfuses RBC in a
two by two basis. Finally, 5 out of 8 institutions have special programmes
for patients who reject transfusion.
Conclusions: There is still variability in clinical practice on transfusion
and other management options. However, a great change in transfusion
paradigms is being made in the Anaesthesia Departments of third-level
hospitals in Madrid.
P37
Patient Blood Management Programme: An Effective
Strategy in a Third Level Hospital
A. Blanco Coronil, V. Guillo Moreno, P. Castello Mora, M. Ortega Gil,
M. Aymerich de Franceschi, S. Arango Uribe & A. I. Peral García
Hospital Puerta de Hierro Majadahonda, Madrid, Spain
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
28 Abstracts of the 16th Annual NATA Symposium
Introduction: Patient blood management (PBM) is an evidence-based,
multidisciplinary approach to optimising the care of patients who
might need transfusion. It is based on three pillars: stimulating ery-
thropoiesis, minimising blood loss and restrictive transfusion strate-
gies. PBM does not only involve a protocol elaboration, but also a
change in transfusion paradigm. We describe the results after starting
the PBM programme in our hospital focused on red blood cells (RBC)
transfusions.
Methods: Data about RBC units transfused in Orthopaedics, Colorec-
tal Surgery and Cardiothoracic Surgery was drawn from the Blood Bank
database. We analysed the months with significant higher rate of surg-
eries between 2011 and 2014. Surgical activity was classified by DRG
(diagnosis related groups). We implemented a PBM programme by steps
according to the three pillars. To minimise blood loss, tranexamic acid
and blood salvage protocols were started in Orthopaedic Surgery and
Cardiothoracic Surgery. A restrictive transfusion strategy was encour-
aged among anaesthesiologists. Finally, we standardised the preopera-
tive treatment of anaemic patients with IV iron therapy, vitamins and
other erythropoiesis-stimulating agents. Awareness of the importance of
PBM for better patient care was approached through lectures and general
meetings.
Results: We did not find any differences related to number of procedures
carried out per year and grouped by RDG. Orthopaedic performed
804 RBC transfusions in 2011, down to 511 in 2014 (36% reduction).
Colorectal surgery experimented a 40% reduction (649 transfusions in
2011, 385 in 2014), and Cardiothoracic surgery, 749 in 2011 and 588 in
2014, assuming 21%.
Conclusion: Implementing a PBM programme implies a change of
mentality and elaboration of evidence based protocols focused on the
three pillars. It is effective to reduce RBC transfusion in major surgeries.
P38
Room for Improvement – Patient Blood Management
in Orthopaedic Patients
C. Donohue & S. Mallett
Royal Free Hospital, London, UK
Introduction: Patient blood management (PBM) is a multidisciplinary
and multimodal approach to better utilisation of blood and products,
based on 3 pillars: optimisation of erythropoiesis, minimisation of blood
loss and improving tolerance to anaemia. It is an emerging priority
for National Health Service Blood and Transplant (NHSBT) in view of
the cost and patient safety implications of blood transfusion. When 2
unit transfusions were analysed in our institution orthopaedic patients
were the most likely group to receive a 2 unit transfusion and have a
post transfusion haemoglobin (Hb) of >100 g/L. We therefore sought to
look at transfusion practice in this patient group specifically in order to
identify scope for improvement measures.
Methods: Details for all patients undergoing elective or emergency
major orthopaedic surgery over a 2 month period (September–October
2014) were obtained. Perioperative Hb values and transfusion practices
were reviewed and analysed using Excel. Statistical analysis was per-
formed using chi-square (𝜒 2 ) and student’s t-test, with p < 0.01 defined
as statistically significant.
Results: 97 patients underwent major orthopaedic surgery (21% emer-
gency and 79% elective) within the study period. 80% did not have a peri-
operative RBC transfusion, 14% received a 2 unit transfusion, 4% had a
single unit transfusion and 1 patient had a 5 unit intraoperative trans-
fusion associated with significant blood loss during revision hip surgery.
When transfusion practice was compared between patients with preop-
erative Hb <120 and >120 g/L, transfusion rates were higher amongst
the anaemic group with statistical significance (52% vs. 5%, 𝜒 2 = 27.124,
p < 0.001). Patients undergoing emergency surgery had higher trans-
fusion rates compared with their elective counterparts, with statistical
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
significance (60% vs. 8%, 𝜒 2 = 30.461 p < 0.001). Mean preoperative
Hb (± SD) was lower in emergency patients compared with elective
(113.5 ± 19.69 and 131.7 ± 12.69 g/L, respectively) but there was no sta-
tistically significant difference on Student’s t-test (p = 3.24). In patients
receiving a 2-unit transfusion, mean post-transfusion Hb (± SD) was
101.1 (±11.63) g/L 7/14 (50%) had a post-transfusion Hb of >100 g/L
and 5/14 (36%) had a post-transfusion Hb of >90 g/L.
Conclusions: Perioperative transfusion rates for major orthopaedic
surgery in our institution are 20% overall, with marked statistically sig-
nificant discrepancies depending on preoperative Hb and urgency of
surgery. Transfused patients are most likely to receive 2 units of RBC.
Up to 86% of these patients may potentially have received unneces-
sary 2nd units of RBC. This snapshot analysis of orthopaedic transfusion
practice highlights several areas for PBM attention: pre-optimisation of
anaemia, use of cell salvage for revision procedures, focus on vulnera-
ble emergency patients and implementation of a single-unit transfusion
policy in stable patients with a move towards more restrictive transfusion
targets.
P39
Implementation of a Patient Blood Management
Programme in Knee Arthroplasty
M. Ortega Gil, P. Castelló Mora, V. Guilló Moreno, S. Arango Uribe, A.
Blanco Coronil & A. Peral García
Hospital Puerta de Hierro Majadahonda, Madrid, Spain
Background: Old transfusion paradigm has recently changed to a
new approach called patient blood management. It consists in opti-
mising preoperative haemoglobin values, reducing perioperative blood
loss, and using restrictive transfusion strategies. IV iron, vitamins or
erythropoiesis-stimulating agents are used for preoperative optimisa-
tion. Tranexamic acid and blood salvage are crucial in second pillar.
We analysed the effect of a patient blood management programme in
patients scheduled for knee arthroplasty.
Material and Methods: We analysed patient blood management in 236
patients in three different periods of time. 51 cases before implementing
a tranexamic acid protocol constituted group A. 82 patients made group
B, once we had implemented the standardised use of tranexamic acid
(TXA), filtered blood salvage in cases of TXA contraindication. Group C
was constituted by 103 cases in which we added a restrictive transfusion
trigger and the optimisation of preoperative anaemia with IV iron,
vitamins and erythropoiesis stimulating agents, if present preoperative
anaemia. We compared preoperative status, postoperative blood loss and
perioperative transfusion between the three groups. Statistical analysis
was carried out by Student’s t-test and Pearson’s 𝜒 2 tests.
Results and Discussion: There were no differences among the three
groups in ASA status, CIM, renal function index and preoperative
haemoglobin. 71% of patients in group B were treated with TXA, and
73% in group C. Perioperative blood salvage was used in 12% of patients
in group B and 7% in group C. Finally, 13% of cases in group C needed
preoperative treatment for anaemia. Postoperative bleeding was sig-
nificantly reduced in Group C compared to Group A (334 ± 403 vs.
651 ± 374 cc; p = 0.000). Day 1 postoperative haemoglobin was signifi-
cantly higher in Group C compared to A (12.2 ± 1.3 vs. 11.5 ± 1.6 g/dL;
p = 0.04) and B (11.5 ± 1.5 g/dL; p = 0.02). Postoperative transfusion was
significantly reduced in Group C compared to Group A (9.7% [95%
CI 3.5–15.9] vs. 27.5% [95% CI 14.2–40.7]; p = 0.004), and Group B
(9.7% [95% CI 3.5–15.9) vs. 23.5% [95% CI 13.6–33.3]; p = 0.011).
The three pillars approach to patient blood management in Group C
resulted in being a protective factor for transfusion with an OR 0.28
(95% CI 0.12–0.70). There were no differences in discharge haemoglobin
values.
Conclusion: A patient blood management programme seems to be, step
by step, a useful tool in reducing transfusion in knee arthroplasty.
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

P40
Implementation of a Patient Blood Management
Programme in Paediatric Scoliosis Surgery
A. Perez-Ferrer, E. Gredilla, J. de Vicente-Sanchez, J. A. García Erce &
F. Gilsanz
La Paz University Hospital, Madrid and San Jorge Hospital, Huesca,
Spain
Introduction: In recent decades the evidence that blood transfusion
leads to worse clinical outcomes, including infection rates, morbidity and
rising costs, is increasing. We aimed to determine whether the imple-
mentation of a blood conservation programme and the adoption and
progressive association of different methods reduces transfusion require-
ments in paediatric patients undergoing scoliosis surgery of diverse aeti-
ologies.
Methods: Experimental, non-randomised, descriptive and analytical
study, approved by the ethics committee for research of our institu-
tion. 50 paediatric patients (ASA I-III) aged 5 to 18 years, undergo-
ing scoliosis surgery of any aetiology by a single posterior or double
approach (anterior and posterior) were included. A historical group with
no alternatives to transfusion: No Saving group = 15 patients (retrospec-
tive data collection) was compared with other three prospective study
groups: AHN (acute normovolaemic haemodilution) group = 9 patients;
ANH + IBS (intraoperative blood salvage) group = 14 patients, and
EPO (ANH + IBS + erythropoietin ± preoperative donation) group = 12
patients; according with the implementation schedule of the transfusion
alternatives in our institution.
Results: The rate of transfusion in different groups (No Saving, ANH,
ANH + IBS, EPO) was 100%, 66%, 57% and 0% of the patients, with
a mean of 3.40 ± 1.59; 1.33 ± 1.41; 1.43 ± 1.50; 0 ± 0 (mean ± SD) RBC
units transfused per patient, respectively. Statistically significant differ-
ences (p < 0.001) in both transfusion rate and number of RBC units was
found.
Conclusions: The application of a multimodal blood transfusion alterna-
tives programme, individualised for each paediatric patient undergoing
scoliosis surgery can prevent transfusion in all cases.
P41
Successful Consecutive Pancreatectomies in Jehovah’s
Witness Patients
J.-O. Lee1 , D. Choi1 , K. Geun Lee1 , H. Park1 , H. Kim1 & M. A. Jeong2
1 Department of Surgery, Hanyang University Hospital, Seoul, Korea;
2 Department Anaesthesiology and Pain Medicine, Hanyang University
Hospital, Seoul, Korea
Introduction: Even though the surgical techniques and perioperative
cares have been improved, blood transfusions are still often required
to the patients undergoing pancreatectomies. But complications from
blood transfusions, poor prognosis of blood transfused patients, cost
and availability of blood products demand transfusion free surgery in
the patients who have pancreatectomies. The purpose of this study is
to verify feasibility of transfusion-free pancreatectomies for Jehovah’s
Witness patients.
Methods: We had investigated the possibility of transfusion-free pan-
createctomies for the Jehovah’s Witness patients underwent pancreatec-
tomies from January 2007 to February 2014. There were 4 cases of Whip-
ple’s operation, 4 cases of pylorus preserving pancreaticoduodenectomy,
2 cases of radical antegrade modular pancreaticosplenectomies and 1
case of laparoscopic distal pancreatectomy performed by one surgeon
for the Jehovah’s Witness patients.
Results: 8 of the 11 patients (72.72%) received preoperative blood aug-
mentation and 9 of the 11 patients (81.81%) received intraoperative acute
normovolaemic haemodilution (ANH). 7 of the 11 patients (72.72%)
received postoperative blood augmentation. The results of showed that
tolerable intraoperative data and postoperative outcomes. There were
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 29
no major complications except grade A pancreatic fistula, postopera-
tive ileus, wound infection. Any transfusions were not done for these
patients.
Conclusions: To our best knowledge, this is the first successful consecu-
tive pancreatectomy programme in Jehovah’s Witness patients without
blood transfusion. Transfusion-free pancreatectomy can be done suc-
cessfully in selected Jehovah’s Witness patients without severe compli-
cations.
P42
Impact of a Transfusion-free Programme on Patients
Undergoing Pancreaticoduodenectomy
Y. B. Jeon1 , S. Yun1 , S. Y. Ok2 , J.-W. Koh3 & D. Choi4
1 Department of Surgery, Soonchunhyang University College of Medicine,
Seoul, Korea; 2 Department of Anaesthesiology, Soonchunhyang
University College of Medicine, Seoul, Korea; 3 Department of Obstetrics
and Gynaecology, Inje University Ilsan Paik Hospital, Ilsanseo-gu,
Goyangsi, Gyeongigo, Korea; 4 Department of Surgery, Hanyang
University College of Medicine, Seoul, Korea
Introduction: Patients undergoing pancreaticoduodenectomy (PD)
often require transfusion. However, transfusion-related complications
and decreased blood donation in Korea encourage the development
of new treatment strategies for PD patients. Although transfusion-free
(TF) operation is thought to be beneficial, results supporting its bene-
ficial effects are lacking. The aim of our study was to demonstrate the
impact on PD patients of a TF programme.
Methods: From December 2003 to April 2013, 80 consecutive patients
with periampullary lesions underwent PD performed. These patients
were divided into 2 groups as follows: 39 PD patients in the ‘before TF
programme’ (group 1) and 41 PD patients in the ‘after TF programme’
(group 2). Among patients in group 2, patients who agreed with the
TF programme were enrolled and proceed with the TF programme
prospectively. Participants in the TF program had perioperative blood
augmentation and intraoperative acute normovolaemic haemodilution.
The perioperative data were compared in the two groups.
Results: The mean preoperative haemoglobin, operative times, and oper-
ative blood loss showed no significance between two groups. The mean
postoperative haemoglobin was lower in group 2 (11.7 vs. 10.9 g/dL,
p = 0.04). The mean amount of blood transfusion was significantly lower
in group 2 (950.8 vs. 124.9 mL; p = 0.00)
Conclusions: The TF programme considerably decreases the amount
of perioperative blood transfusion. The overall perioperative course
and complication rate in the TF group were not inferior to those in
the non-TF group. The TF programme appears safe and should be
considered in PD patients.
P43
Patient Care Procedures for People Refusing Treatment
with Blood Derivatives
J. M. Esparza Miñana, E. Romero, M. Belaouchi & C. Garcia
Hospital de Manises, Valencia, Spain
Introduction: Manises Health Department includes among its care
strategy approaches a “General Plan of Blood Product Management”
extending to all assigned population. The objective of this plan is to per-
form a rational use of blood, limiting its use and indications to those
strictly necessary. Within the blood product management general policy
and since the end of 2012, patients rejecting the administration of blood
derivatives because of religious reasons (Jehovah’s Witnesses) were began
to be attended.
Material and Methods: 101 patients, 99 included because of confes-
sional reasons (Jehovah’s Witnesses) and 2 because other reasons. 76
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
30 Abstracts of the 16th Annual NATA Symposium
women (75.2%) and 25 men. It should be noted the inclusion of 5
minors. The surgeon in charge determines the bleeding risk and the
benefit of the intervention. In the previous anaesthetic consultation the
anaesthetic-surgical risk is determined and the necessary information
for the patient to take an informed decision is provided. The differ-
ent therapeutic alternatives are explained to the patient who accepts or
rejects the document named “Therapeutic options for patients reject-
ing blood transfusion”. The patient is also given the information about
“General strategy for bloodless surgery techniques management”. Finally
a consensus on “Individualised strategy for bloodless surgery manage-
ment” is established. We optimise haemoglobin levels if patient presents
Hb < 13 g/dL in men or Hb < 12 g/dL in women. The “Bloodless Surgery
Committee” has usually a meeting to evaluate and study the most com-
plex cases and decides which type of preparation should be done, the
surgical technique required. The different anaesthetic approaches and
the use of intra-operatory and post-operatory recovery substances are
also determined.
Results: The complications rate has been really low. 3 patients passed
away but none of them due to bleeding. One deceased because of
multi-organic failure and the other two because of progression of their
oncologic disease. It is worth highlighting the fact of one bleeding
complication. It was postpartum haemorrhage related to uterine atony
requiring hysterectomy, anexectomy and hypogastric arteries ligation
along with long term stay in Critical Care Unit.
Conclusions: The interdisciplinary approach in patients rejecting treat-
ment with blood products has demonstrated to be an adequate procedure
to achieve a low rate of complications. From a legal perspective, patients
have the right to reject blood transfusions or treatment with blood prod-
ucts, having the professional the obligation to respect such decisions and
Public Administration have the obligation of act as a guarantor of those
rights. The implementation of consensual protocols, as well as the ful-
filling of legal informed consent documents of agreement or rejection to
certain therapies, has resulted to be an adequate tool because of the wide
range of acceptation among patients as well as the low rate of complica-
tions derived from them.
P44
Postoperative Use of Autotransfusion Drainage System
in Cardiac Surgery Patients
E. Ambarkova Vilarova, T. Anguseva, N. Hristov & Z. Mitrev
Special Hospital “Filip Vtori”, Skopje, Macedonia
Introduction: Transfusion red blood cells (RBCs) is often required dur-
ing cardiac surgery due to significant blood loss. Postoperative autotrans-
fusion as a blood saving technique involves the infusion of mediastinal
shed blood after cardiac surgery as an attempt to minimize the use of
homologous packed red blood cells (PRBCs). The aim of this study was
to ascertain whether postoperative use of autotransfusion drainage sys-
tem after cardiac surgery is associated with significant reduction in the
use of homologous PRBCs.
Methods: In a retrospective analysis we collected data on the use of
PRBCs in 392 elective cardiac surgery patients (coronary artery graft-
ing, valve replacement and reconstruction and complex operations).
The patients were divided into two groups: 199 patients where we used
an autotransfusion drainage system postoperatively (Cardiopulmonary
Post-operative Autotransfusion System, EUROSETS) and 193 patients
where we did not use this system. Internal hospital protocol for ratio-
nal use of blood and blood components was applied for all patients. We
noted the reported side effects that could be associated with autotrans-
fusion.
Results: There were no serious adverse effects in the group where the
autotransfusion drainage systems were used. Two patients after rein-
fusion had mild adverse effects, fever (t >38 ∘ C) and shivering. The
patients in autotransfusion group received 116 PRBCs and the patients in
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
the group where the autotransfusion system was not used received 180
PRBCs; the difference was statistically significant lower (p < 0.01). The
PRBCs transfusion rate was lower (43%) in the autotransfusion group
than in the group of patients where the autotransfusion systems were
not used (59%).
Conclusion: Postoperative use of autotransfusion drainage system in
cardiac surgery is a safe method for blood restriction and provides
significant reduction in the use of homologous RBCs in cardiac surgery
patients.
P45
Characteristics and Quality of Intraoperative Cell Salvage
in Paediatric Scoliosis Surgery
A. Perez-Ferrer, E. Gredilla, J. de Vicente-Sanchez, R. Navarro-Suay, J.
A. García Erce & F. Gilsanz
La Paz University Hospital and Gomez Ulla Hospital, Madrid, Spain; San
Jorge Hospital, Huesca, Spain
Introduction: The use of perioperative blood salvage in paediatric
surgery remains controversial and research on their effectiveness, the
quality of the product and the right type of cell-saver for children is
scarce. This study was designed to determine the haematological and
microbiological characteristics of blood recovered by using a cell-saver
with a rigid centrifuge bowl (100 mL) in paediatric scoliosis surgery and
check whether it conforms to the standard expected in adult patients.
Methods: Cross sectional study, descriptive cohort of 24 consecu-
tive RBC units recovered from the surgical field and processed by a
Haemolite® 2+ (Haemonetics Corp., Braintree, MA, USA) cell saver.
Data regarding age, weight, surgical approach (anterior or posterior),
processed shed volume and volume of autologous red blood cells (RBC)
recovered, haemogram parameters and blood culture obtained from the
RBC concentrate and incidence of fever after reinfusion were collected.
Results: The processed shed volume was very low (939 ± 569 mL) with
high variability (coefficient of variation = 0.6), unlike the recovered vol-
ume 129 ± 50 mL (coefficient of variation = 0.38). Statistically significant
correlation between the processed shed volume and recovered RBC con-
centrate haematocrit was found (Pearson, p = 0.001). Haematological
parameters in the recovered concentrate: Hb 11 ± 5.3 g/dL; haematocrit:
32.1 ± 15.4% (lower than expected); leukocyte 5.34 ± 4.22 x 103 /μL;
platelets 37.88 ± 23.5 x 103 /μL (mean ± SD). Blood culture was posi-
tive in the RBC concentrate recovered in 13 cases (54.2%) in which
coagulase-negative Staphylococcus was isolated.
Conclusions: Cell salvage machines with rigid centrifuge bowls (includ-
ing paediatric small volume) do not obtain the expected haematocrit if
low volumes are processed and therefore they are not the best choice in
paediatric surgery.
P46
Fat Removal during Cell Salvage – Comparison of Devices
and Programmes
T. Seyfried, L. Haas, M. Gruber & E. Hansen
Department of Anaesthesiology, University Hospital Regensburg,
Regensburg, Germany
Introduction: Fat in wound blood seen in orthopaedic or cardiac
surgery might pose a risk for fat embolism during blood salvage. Prior
studies have shown an excellent fat removal by the continuous autotrans-
fusion device CATS (Fresenius, Germany) in contrast to systems using a
Latham bowl, but suffer from testing with oil and not taking into account
the role of process parameters.
Methods: ABO-matched blood from fresh volunteer donations was
adjusted to a haematocrit of 25% (“cardiac”) and 1.25% human tissue fat
added. Volumetric quantification of fat was performed after centrifuga-
tion of blood samples in Pasteur pipettes (according to Engstrom) with
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

a sensitivity of 0.04 vol%. From the volumes, the Hcts and the concen-
trations of fat RBC recovery and fat elimination rates were calculated.
Different devices (CATS®, Fresenius-Kabi; Cell Saver V + ®, Haemon-
etics; Electa®, Sorin; and XTRA®, Sorin) and programs including Pfat,
an optimised fat removal program for XTRA, were tested.
Results: The continuous system CATS® consistently showed a high fat
removal rate of 99.8% ± 0.2%. Fat accumulated in the wash disposal, but
not in the product. In the Latham bowl based discontinuous systems fat
removal varied depending on the programme mode, but not on the bowl
size. It increased from 69.2 ± 2.5% in the standard programme Pstd to
89.2 ± 4.3% with the (for Hct) optimised programme Popt . Additional fil-
tration increased fat removal to 96.7 ± 2.2%, but also increased red blood
cell loss. With the fat removal program Pfat . in XTRA® fat elimination
reached 98.5 ± 2.3%, not significantly different to CATS®. RBC recov-
ery rate and elimination rates of other constituents like potassium and
free plasma haemoglobin remained high. Fat removal showed no ceiling
effect.
Conclusions: Fat removal capacities of discontinuous systems depend
on the programme mode, and can be improved by filtration. A special
programme modification Pfat involving extra washing and RBC concen-
tration steps significantly increases fat removal by the Latham bowl based
autotransfusion device XTRA®, thus yielding results equivalent to the
continuous cell salvage system (CATS®).
P47
Development of a Surgical Swab Washing Device
S. Haynes1 , J. Corden2 & M. Jameel3
1 University Hospital of South Manchester, Manchester, UK; 2 TrusTech,
Manchester, UK; 3 University Hospital of Wrightington, Wigan and Leigh,
Wigan, UK
Introduction: The efficiency of intraoperative cell salvage (ICS) relies
on maximizing the amount of blood collected from the patient. Surgical
bleeding is usually collected by aspiration through a surgical suction
catheter which is then directed to a cell salvage machine. Depending on
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 31
the type of surgery or individual surgeon a significant amount of blood is
also soaked up within surgical swabs. Washing swabs in saline to release
red cells from the swabs is a proven technique for collecting these cells1
but there remains no consistent method or device that can perform this
process efficiently with no risk to the operator. We undertook a project
to design an automatic mechanical device to replace the manual swab
washing process.
Methods: A series of laboratory based experiments were undertaken
to investigate the swab washing process using date expired allogeneic
human blood. The purpose of these experiments was to identify the
efficiency of the existing manual swab washing process in terms of
extraction of fluid and recovery of viable red cells. A number of test rigs
were designed and manufactured that incorporated different methods
of soaking, agitating and squeezing blood soaked swabs. The extraction
efficiency of these automatic washing processes was then compared to
the established manual washing process.
Results: The efficiency of red cell recovery by manual agitation in saline
and hand wringing was determined as (mean ± standard deviation)
75.8 ± 8.3%. A number of mechanical methods of agitation, swab com-
pression and fluid evacuation were evaluated using the different test rigs.
The most efficient method involved orbital agitation and vacuum com-
pression of the swabs. Optimisation of the process parameters enabled
red cell recovery rates in excess of 80% to be achieved. Morphological
studies confirmed the integrity of the red cells recovered by mechanical
processes.
Conclusion: We designed a mechanical device that efficiently removed
viable red cells from surgical swabs. As a result of this work UK and
International patents have been filed and a spin out company formed
(SwabTech Ltd). The next step is to undertake clinical trials with the
prototype device in order to validate our laboratory studies.
REFERENCE
1. Haynes SL, Bennett JR, Torella F, McCollum CN. Does washing
swabs increase the efficiency of red cell recovery by cell salvage in aortic
surgery? Vox Sang 2005;88:244-8.
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
32 Abstracts of the 16th Annual NATA Symposium
ANAEMIA EFFECTS AND MANAGEMENT
P48
Anaemia Management Service: The First Pillar of Patient
Blood Management
A. Allameddine, M. Heaton, H. Jenkins, H. Morris, S. Andrews, B.
Sedman, C. Porada & S. Flynn
The Pennine Acute Trust, Manchester, UK
Iron deficiency is the most common cause of anaemia worldwide and
many patients with iron deficiency anaemia are often given blood trans-
fusion, inappropriately. Although blood products remain a critical ele-
ment of clinical practice, there is increasing evidence that a significant
proportion of transfusions are unnecessary or could have been avoided.
Nevertheless, allogeneic transfusions can be associated with adverse
patient outcomes, potentially leading to increased morbidity, resulting
in delayed recovery or extended hospital stays and increased level of
mortality.
The National Comparative Audit of Blood Transfusion conducted in July
2013, by the Royal College of Physicians, in collaboration with NHS
Blood and Transplant, and other similar audits conducted in Pennine
Acute Hospitals NHS Trust, showed that at least 20% of transfused
patients had anaemia possibly treatable by means other than red cell
transfusion.
The Pennine Acute Hospitals NHS Trust established the Anaemia Man-
agement Service as part of a patient blood management (PBM) pro-
gramme to support the effective management and conservation of the
patient’s own blood. This is an integrated service and offers, both hospi-
tal clinicians and General Physicians in the community, a direct referral
pathway for patients with iron deficiency anaemia, who are intolerant to
oral iron or when the time scale before surgery is limited, to be directly
referred to a Day Clinic at a number of hospital sites within the Trust, for
intravenous iron treatment.
The service is a nurse-led allowing an easy and rapid access to intra-
venous iron treatment and would help offering better patient experience
and avoid unnecessary hospital admission and potentially unsafe blood
transfusion. The use of IV iron will also support the preoperative path-
way, avoid delays in surgery and help reduce hospital length of stay.
P49
Correct Management of Anaemia as Real Alternative
to Blood Transfusion in Multicentre Hospital
Y. K. Hakobyan
Haematology Centre after Prof. Yeolyan MH RA, Yerevan, Armenia
Background: Anaemia is a great problem not only for haematologists
but also for other specialists too. Anaemia is a serious problem especially
in developing countries where patients’ and public’s medical educational
level is very low, especially in risk group of people: children, pregnancies,
patients with chronic diseases, elders.
Aims: Right diagnosis of anaemia in early stage of disease and adequate
treatment will allow correcting the level of haemoglobin without blood
transfusions.
Materials and Methods: During 2003–2007 was consulting 793 patients
in different departments of Erebouni MC. 635 (80%) of patients had
various level anaemia and 158 (20%) of patients were diagnosed another
haematological pathologies. Iron deficiency anaemia was diagnosed in
559 (70%) cases: patients with different kind of primary pathology
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
(diabetes, renal failure, pneumonia, etc.). Iron-deficiency anaemia was
certified by blood, serum iron and ferritin tests. In 76 (10%) cases were
diagnosed B12 and folic acid deficiency anaemia: patients with liver,
stomach diseases or after operation. Critical ill patients did not include
in the investigation group.
Results and Discussion: We recorded significant increasing Hb and
RBC levels of 369 (66%) patients in the moment of leaving the hospital.
In general we used per oral medicaments and only by contra-indication
(gastric problems, etc.) prescribed as intramuscular medication. Thanks
to adequate treatment of anaemia and successful cure of initial pathology
in 503 (90%) cases we had a success in escaping from blood transfusion.
Only in 56 (10%) cases transfused RBC: one unit RBC per case, maxi-
mum three units RBC for two cases. After hospital discharge the treat-
ment of 363 (65%) patients was under control and during two months we
have reached Hb and RBC normal levels in 295 (81%) cases. 146 (26%)
patients were out of control and 28 (5%) patients stopped anti-anaemic
treatment due to intensification of basic pathology. At the same time 22
(4%) patients interrupted treatment due to side effects of drugs (stom-
ach pain, nausea, diarrhoea, etc.). It is very important that patients and
relatives understand the problems which helps to carry out adequate and
right treatment program showing high results.
Conclusions: Anaemia is a very commonly diagnosed disease in the
multi-field hospital. The adequate correction of anaemia is a very impor-
tant part of treatment which allows us to avoid lots of complications
including RBC transfusions. Right treatment of anaemia is helping to
ease the clinical course of primary pathology. At the same time it is
very important to increase the information and understanding level of
patients. The high level of knowledge on anaemia will help to make right
diagnosis in the early stage of disease and to provide right and adequate
treatments. After all, the treatment results in increasing the patients’
quality of life.
P50
Preoperative Anaemia in Colorectal Surgery
J. Gudaitytė1,2 , E. Šalčiūtė2,3 & V. Šaferis4
1 Department of Anaesthesiology, Medical Academy, Lithuanian
University of Health Sciences, Kaunas, Lithuania; 2 Medical Academy,
Lithuanian University of Health Sciences, Kaunas, Lithuania; 3 Vilnius
University, Faculty of Medicine, Vilnius, Lithuania; 4 Department
of Mathematics, Physical and Biophysical Sciences, Lithuanian University
of Health Sciences, Kaunas, Lithuania
Introduction: The incidence of preoperative anaemia in colorectal
surgery ranges from 35 to 75%. This condition increases both morbidity
and mortality. Our goal was to determine the rate of anaemia, its man-
agement and effect on recovery after elective colorectal surgery in the
Hospital of Lithuanian University of Health Sciences.
Material and Methods: After receiving the approval by local Com-
mittee of Bioethics, a retrospective study was conducted. We included
colorectal surgery patients aged ≥18 years who had undergone the
surgery from January to November 2013. Analysis was based on demo-
graphic information, total blood count before and after surgery, periop-
erative management of anaemia, postoperative complications and out-
comes. Anaemia was diagnosed applying the criteria of WHO: the level
of haemoglobin (Hb) <120 g/L for females and <130 g/L for males.
SPSSv17.0 software package, Student t, Mann-Whitney U, Pearson chi2
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

and Fisher’s tests were used for statistical analysis with p < 0.05 regarded
as statistically significant.
Results: The rate of anaemia was 15.2% according to medical records.
However, the application of WHO criteria resulted in the rate of 53%.
Comparison of anaemia group (n = 80) and control group (n = 71)
revealed no difference in age, 70 ± 11 and 68 ± 9 years, respectively. How-
ever, the male/female ratio in anaemia vs control group was 31.2/68.8%
vs. 71.8/28.2% (p < 0.01). Groups were comparable with respect to the
rate of postoperative complications and outcomes: cardiac arrhythmia,
ischaemic events, wound infection, anastomotic leakage, mortality and
hospital stay. However, the mean level of preoperative Hb was lower
in patients who had cardiac ischaemic events, 87 ± 33 vs. 123 ± 19 g/L
(p < 0.05). According to medical records, anaemia was treated with oral
iron in 5 cases. 15 patients treated with RBC transfusion had a lower level
of Hb compared with non-transfusion group (93 ± 22 vs. 125 ± 18 g/L,
p < 0.01), higher rate of ischaemic events (13.3 vs. 1.5%, p < 0.05), anas-
tomotic leakage (20 vs. 1.7%, p < 0.05) and longer hospital stay (17.3 ± 10
vs. 10 ± 4 days, p < 0.05).
Conclusion: The incidence of anaemia in patients of elective colonic
surgery exceeded 50%. It had no effect on the rate of other postoperative
complications; however, a lower level of preoperative Hb was associated
with a significant increase in postoperative cardiac ischaemia. The rate of
ischaemic events, as well as anatomotic leakage and prolonged hospital
stay was also increased by RBC transfusion.
P51
Preoperative Haemoglobin Concentration,
Cardiopulmonary Exercise Testing and Postoperative
Outcome
J. M. Otto1 , A. F. O’Doherty2 , R. S. Moonesinghe3,4 , R. C. M.
Stephens3 , D. S. Martin5 ; H. E. Montgomery6 & T. Richards1
1 Division of Surgery and Interventional Science, University College
London, London, UK; 2 Department of Sport, Health and Exercise
Science, University of Hull, Hull, UK; 3 Centre for Anaesthesia, 3rd Floor
Maple Link Corridor, University College London Hospital, London, UK;
4 Surgical Outcomes Research Centre (SOuRCe), University College
London Hospital, London, UK; 5 Divisional of Surgery and Interventional
Science, Royal Free Hospital, University College London, London, UK;
6 Institute for Human Health and Performance, University College
London, and NIHR University College London Hospitals Biomedical
Research Centre, London, UK
Introduction: Major surgery places an increased burden of aerobic
metabolism upon the patient. Preoperative Cardiopulmonary Exercise
Testing (CPET) assesses the ability of the body to meet such demands,
providing metrics such as peak exertional oxygen consumption (vO ̇ 2
peak) and anaerobic threshold (AT: the point at which anaerobic
metabolism makes a significant contribution to overall metabolism).
Reductions in both are associated with increased postoperative morbid-
ity and mortality.1,2 Anaemia is defined as a haemoglobin concentration
([Hb]) of <130 g/L in men and 120 g/L in non-pregnant women, and
is associated with a reduction in both vO ̇ 2 peak and AT.3-5 Anaemia
is common preoperatively and is associated with poor outcome after
surgery.6,7 Additionally, red blood cell transfusion (RBCT) used to treat
anaemia may also contribute to adverse perioperative outcome.8 We
sought to characterise these associations further and hypothesised that
reduced [Hb] may impact on perioperative outcome in part through
altered indices of fitness.
Methods: Between July 2011 and May 2014 patients at University College
London Hospital underwent routine preoperative CPET. Preoperative
[Hb] was assessed with anaemia defined according to WHO criteria9 .
Postoperative morbidity (assessed by the Postoperative Morbidity Sur-
vey, POMs) was also routinely recorded on the 8th postoperative day
(POD8), as was total hospital length of stay (LOS) both blind to CPET.
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 33
Results: 275 patients (176 male) were studied [(median (IQR) age 66
(59-74) years; mean ± SD weight 77.1 ± 18.5 kg)], of whom 117 (42.7%)
were anaemic. [Hb] correlated with total oxygen consumption (L. min-1 )
at AT (r = 0.496, p < 0.0001) and vO ̇ 2 peak (r = 0.489, p < 0.0001).
CPET-derived vO ̇ 2 at AT was thus lower in anaemic than non-anaemic
patients (9.3 ± 2.1 ml. kg-1 min-1 versus 10.9 ± 2.1 ml. kg.-1 min-1 ,
p < 0.0001), as was vO ̇ 2 peak (14.1 ± 3.9 ml. kg.-1 min-1 versus
17.5 ± 4.9 ml. kg.-1 min-1 , p < 0.0001). Similarly, anaemic patients were
more likely to have an AT a prognostically significant <11 ml. kg.-1 min-1
(OR 3.94, 95% CI 1.99-7.78, p < 0.0001). Overall, 200 patients (72.7%)
had a POMs-defined morbidity on POD8. Anaemic patients were
less likely to be morbidity free on POD8 (OR 0.39, 95% CI 0.18-0.83,
p = 0.015) after extended adjustment and anaemia prolonged the dura-
tion of morbidity [15 (8-21) days versus 8 (5-21) days, p = 0.018]. In
total 44 patients received a RBCT, of whom 30 (68.2%) were anaemic
and 41 (93%) had morbidity on POD8. Therefore, RBCT reduced
the likelihood of being morbidity free on POD8 (OR: 0.16, 95% CI
0.04-0.54, p = 0.003).
Conclusion: Anaemia was common preoperatively and reduced the like-
lihood of a patient being morbidity free. Anaemia resulted in greater
RBCT use, itself contributing to postoperative morbidity. Anaemic
patients had impaired fitness below prognostically significant values,
which may in part contribute to a predisposition to excess perioperative
morbidity.
REFERENCES
1. Older P, Smith R, Courtney P, Hone R. Preoperative evaluation of
cardiac failure and ischemia in elderly patients by cardiopulmonary
exercise testing. Chest 1993;104:701-4.
2. Snowden CP, Prentis JM, Anderson HL, et al. Submaximal car-
diopulmonary exercise testing predicts complications and hospital
length of stay in patients undergoing major elective surgery. Ann Surg
2010;251:535-41.
3. Otto JM, O’Doherty AF, Hennis PJ, et al. Association between preop-
erative haemoglobin concentration and cardiopulmonary exercise vari-
ables: a multicentre study. Perioper Med (Lond) 2013;2:18.
4. Cohen-Solal A, Keteyian SJ, Horton JR, Ellis SJ, Kraus WE, Kilpatrick
RD. Association between hemoglobin level and cardiopulmonary per-
formance in heart failure: insights from the HF-ACTION study. Int J
Cardiol 2013;168:4357-9.
5. Agostoni P, Salvioni E, Debenedetti C, et al. Relationship of rest-
ing hemoglobin concentration to peak oxygen uptake in heart failure
patients. Am J Hematol 2010;85:414-7.
6. Baron DM, Hochrieser H, Posch M, et al. Preoperative anaemia is
associated with poor clinical outcome in non-cardiac surgery patients.
Br J Anaesth 2014;113:416-23.
7. Musallam KM, Tamim HM, Richards T, et al. Preoperative anaemia
and postoperative outcomes in non-cardiac surgery: a retrospective
cohort study. Lancet 2011;378:1396-407.
8. Glance LG, Dick AW, Mukamel DB, et al. Association between intra-
operative blood transfusion and mortality and morbidity in patients
undergoing noncardiac surgery. Anesthesiology 2011;114:283-92.
9. World Health Organization. Haemoglobin concentrations for
the diagnosis of anaemia and assessment of severity. Vitamin and
Mineral Nutrition Information System. Geneva: World Health
Organization; 2011.
P52
Anaemia and Patient Blood Management Implementation
in Liver Transplantation
B. Clevenger, T. Richards & S. V. Mallett
Royal Free Hospital, London, UK
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
34 Abstracts of the 16th Annual NATA Symposium
Introduction: Orthotopic liver transplantation (OLT) is a life-saving
intervention in end-stage liver disease. Improvements in surgical and
anaesthetic management have reduced intraoperative transfusion rates
significantly with a median transfusion rate of 5units RBCs common.1
However, there is significant inter-centre variability in transfusion prac-
tice. The full application of patient blood management (PBM) to reduce
unnecessary transfusion and improve patient outcome has not yet
been seen in liver transplant practice, particularly pre-optimisation of
anaemia.
Methods: Intravenous iron (ferric carboxymaltose) was introduced for
the treatment of preoperative anaemia in liver transplant candidates
at our institution. All patients presenting for assessment for addition
to the liver transplant waiting list were audited between April and
December 2014. Eligibility criteria was addition to the transplant waiting
list, with a haemoglobin concentration <110 g/L, with ferritin <100 μg/L
or 100-299 μg/L with transferrin saturation <20%; as per commonly
accepted definitions of iron deficiency.2
Results: 122 patients were assessed for OLT over this period. Mean
Hb was 109.5 g/L (SD 21.0) and 66 patients (50%) were anaemic (Hb
<110 g/L). Of anaemic patients, only 3 had a microcytic anaemia (MCV
<79 fL). 10 anaemic patients did not have haematinics measured. 20/56
(35.7%) of anaemic patients had a low ferritin (<100 mcg/L) and
whilst a further 5 had ferritin 100–299 μg/L with transferrin satu-
ration <20%. 19 had elevated ferritin >340 μg/L (median 173.5 μg/L
[IQR 67.5–462.8]). 24/56 (42.9%) of anaemic patients had low iron
(Fe <11 μmol/L) whilst none had high total iron (median 14.35 μmol/L
[IQR 8.43-22.18]). 17/56 (30.4%) had low transferrin saturation (<20%)
whilst 21/56 (37.5%) had high transferrin saturation (>20%) (median
34.65% [IQR 17.6–55.7]). 41/56 (73.2%) had a low total iron binding
capacity (TIBC <53 μmol/L) whilst none had a high TIBC [median
44.65 μmol/L [IQR 37.45–55.3]]. No anaemic patients had low vitamin
B12 (<160 ng/L) or folate (<3.8 μg/L).
Conclusion: Anaemia is prevalent in patients with liver disease being
considered for OLT. Despite concerns about iron overload in patients
with liver disease, iron deficiency is prevalent, with 44% of anaemic
patients having accepted criteria for absolute or functional iron defi-
ciency. More clinical focus upon treatment of preoperative anaemia is
needed in this group of patients to reduce transfusion rates.
REFERENCES
1. Ozier Y, Pessione F, Samain E, Courtois F. Institutional variabil-
ity in transfusion practice for liver transplantation. Anesth Analg
2003;97:671-9.
2. Clevenger B, Richards T. Pre-operative anaemia. Anaesthesia 2015;70
Suppl 1:20-e8.
P53
Preoperative Optimisation of Anaemic Patients: A Task
to Reduce Blood Transfusions at Puerta de Hierro Hospital
in Madrid
S. Arango, M. Ortega, V. Guilló, P. Castelló, A. Blanco & A. I. Peral
Hospital Universitario Puerta de Hierro, Madrid, Spain
Introduction: Preoperative anaemia is common and strongly associated
to perioperative red blood cell (RBC) transfusion. Although traditional
management has been blood transfusion, recent meta-analysis have
shown that it increases overall complications. A global initiative to
reduce the number of transfusions is taking place. The purpose of this
study is to review the first year of experience in treating preoperative
anaemia for Patient Blood Management in a third level hospital.
Methods: We retrospectively reviewed anaemic and ferropenic patients
scheduled for non-cardiovascular surgery from June 2013 to July 2014.
They were referred from Anaesthesia Preoperative Evaluation Unit
for preoperative optimisation. We collected data such as age, type of
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
anaemia, treatment provided and therapeutic success (considered as
haemoglobin ≥12 g/dL). Statistical analysis was performed with SPSS
program (percentage and median values).
Results: 175 patients were optimised out of 16 625 elective surgical
procedures. The median age was 69 years, 38% men and 62% women.
Most patients were scheduled for orthopaedic (42%), general surgery
(25%) and gynaecology (12%) procedures. There were 3 Jehovah’s Wit-
ness patients. The most frequent diagnoses were anaemia (60%) and fer-
ropenia (29%). Anaemia was ferropenic in origin in 50% of cases, 10%
related to chronic disease and mixed in 40%. Documented rate of ther-
apeutic success was 72%. 21% of the patients did not reach Hb values
≥12 g/dL, most of them (76%) were oncological cases and there was not
enough time to complete the treatment. 7% of the patients did not have
a blood test after the treatment. 9% of the cases received erythropoietin
as part of the treatment; they were previously diagnosed with anaemia
related to chronic disease or mixed anaemia. 10% of the patients received
perioperative RBC transfusions: 0.6% preoperative, 2.9% intraoperative
or during the first 24 hours post-surgery (indicated by an anaesthesiolo-
gist), 4% after 24 hours post-surgery (indicated by a surgeon) and 2.5%
received more than one postoperative transfusion.
Conclusions: We reached an important rate of therapeutic success and
observed a low perioperative RBC transfusion percentage in optimised
patients, which is consistent with the current literature. However, it is
still difficult to optimise oncologic patients because of the limited time
before the surgery.
P54
An Intravenous Iron Based Protocol for Optimising
Haemoglobin in Anaemic Patients Prior to Fast Track Hip
and Knee Arthroplasty – An Observational Follow Up Study
O. Jans & H. Kehlet
Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen,
Denmark
Introduction: Patients presenting with preoperative anaemia prior to
hip and knee arthroplasty has a high risk of receiving allogeneic blood
transfusion and anaemia has been associated with increased postoper-
ative morbidity and mortality. While IV-iron administration may raise
Hb prior to surgery, existing guidelines for addressing and treating pre-
operative anaemia is not widely implemented for patients scheduled for
elective total joint arthroplasty (TJA) in Denmark. In addition, causes of
preoperative anaemia and the efficacy of preoperative IV-iron adminis-
tration in elective TJA have not been sufficiently evaluated.
Methods: This ongoing study is a observational follow-up study among
6 Danish high volume surgical centres that has recently introduced
a standardised anaemia screening and treatment protocol for patients
with preoperative anaemia (Hb <12 g/dL female, Hb <13 g/dL male)
scheduled for total hip or knee arthroplasty.
Patients with iron deficiency anaemia (ferritin <100 nmol/L & TSAT
<20%) or anaemia of chronic inflammation (ferritin >100 nmol/L &
TSAT <20%) receive infusion of IV iron (Monofer© ) 4 weeks prior to
surgery.
We plan to include 300 preoperative anaemic patients during a 2-year
period.
The following outcome measures are evaluated:
• Transfusion rates during admission (primary outcome)
• No. of transfusions administered per patient
• Hb increase from treatment to day of surgery
• No. of patients normalising Hb prior to surgery
• Anaemia type
• Length of stay
• Readmission <90 days
Funding: This study is supported by an unrestricted research grant from
Pharmacosmos A/S.
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

P55
A Pragmatic Clinical Use of the Ferric Carboxymaltose Tool:
Pre-surgical Treatment of Anaemic or Iron Deficiency
in Patients with Colorectal Neoplasm
L. E. Gutiérrez Cantero1 , S. García Orallo2 & J. Rodríguez García3
1 Surgery Department, 2 Anaesthesiology Department,
3 Infection-Epidemiology Department, Sierrallana Hospital, Torrelavega,
Spain
Introduction: The importance of iron metabolism in surgical patient
with colorectal cancer (CRC) is well known both its implications in
the postoperative course and immediate-mediate complications. To
explore the preoperative anaemia management in our hospital, we
reviewed a sample of 58 CRC patients operated during 2013. The results
show us 58.6% patients with light to moderate preoperative anaemia
(Hb <13 g/dL), 22.4% moderate to severe preoperative anaemia (Hb
<10 g/dL), few patients had a previous iron study, poor preoperative
treatment with sporadic use of oral or intravenous iron. 41% patients had
any postoperative complication; higher complications in patients with
postoperative anaemia was observed. Transfusion rate was 27.5%. We
concluded it was necessary a protocol to treat anaemia or iron deficiency
in preoperative patients with CRC.
Methods: Multidisciplinary session to discuss and approve the
protocol in CRC patients. We established inclusion criteria, four
possible patient iron dose categories, a restrictive transfusion ther-
apy to get stable haemoglobin levels, and a follow up datasheet and
database. We follow up oncologic treatment and posterior surgical
reviews.
Results: To date we have included five patients in protocol. None of them
were transfused nor suffered postoperative complications.
Hb pre IV
iron Transferrin Serum Days from
treatment saturation ferritin treatment to Pre-surgical Post-surgical
(g/dL) index (%) (μg/dL) surgery Hb (g/dL) Hb (g/dL)
10.2 (3.1) 6.4 (3) 31 (59) 19 (9.5) 11.7 (4.2) 9.8 (1.8)
Values presented as median (interquartile range)
Although it may not draw solid conclusions yet, we expect an increase of
Hb levels after iron therapy, lessen transfusion requirements and improve
postoperative anaemia and complications.
Conclusions: Intravenous iron is both efficient and safe for the treatment
of preoperative iron deficiency and anaemia in CRC patients. Reduces
transfusion requirements and may improve results. Hence the reason
why we decided an improvement plan of treatment and follow up in this
patients.
P56
Clinical Response to Preoperative Intravenous
Administration of Ferinject®: A Portuguese Observational,
Retrospective, Multicentre Study
J. Martinez1 & C. Aldeia2
1 Serviço
de Imuno-Hemoterapia, Centro Hospitalar Cova da Beira,
Fundão, Portugal; 2 Serviço de Imuno-Hemoterapia, Hospital do Litoral
Alentejano, Santiago do Cacém, Portugal
Introduction: Patients with iron deficiency anaemia (IDA) are more
vulnerable during surgeries, have a higher postoperative morbidity
and mortality and require more blood transfusions. To reduce trans-
fusions during and after surgery and postoperative complications, the
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 35
administration of preoperative intravenous (IV) iron therapy has been
implemented. The study aimed to compare haemoglobin (Hb), ferritin
and transferrin saturation (TSAT) values at baseline and at discharge in
a population of IDA patients, undergoing surgery, which were admin-
istered IV ferric carboxymaltose (FCM). Number of blood transfusions
and adverse events were also accounted.
Methods: Observational, retrospective, multicentre study, involving
IDA patients from two Portuguese hospitals, submitted to surgery after
FCM administration. Data were collected between 2012 and 2014. Each
patient had their Hb, ferritin and TSAT values recorded, before surgery
and at hospital discharge. FCM doses, number of day care hospital treat-
ment sessions and number of transfusions were also documented. Sta-
tistical analysis was performed using SPSS IBM software v. 22.
Results: 267 patients, 76 men (28.5%) and 191 women (71.5%), mean
age of 62.2 ± 18.4 years (range 18–96), were enrolled. FCM was admin-
istered at a minimum dose of 500 mg and a maximum of 2000 mg.
Most frequently administered doses were 800 and 1500 mg (19.9 and
18.4%, respectively). Baseline mean values of Hb (g/dL), ferritin (ng/mL)
and TSAT (%) were 9.7 ± 1.2, 22.7 ± 63.5, 8.7 ± 5.9; and, at discharge
11.9 ± 1.6, 247.8 ± 256.3, 29.7 ± 13.2, respectively. Results for Hb, fer-
ritin and TSAT were statistically significant comparing baseline with dis-
charge (p < 0.001). Most patients (57.7%) required two day care hospital
treatment sessions and 211 (79.3%) did not receive any blood transfu-
sion. No adverse events were reported.
Conclusion: Preoperative IV FCM administration significantly
improved patients’ clinical response, regarding iron blood stores,
and a marked reduction of blood transfusions occurrence. FCM was
safe and well tolerated by the patients.
P57
Patient Recruitment for PREVENTT, a Preoperative Anaemia
Trial: Single Centre Experience
H. Lawrence, K. Horner, M. Koutra, E. Black, E. Todman, S. Jhanji
& R. Rao Baikady
The Royal Marsden NHS Foundation Trust, London, UK
Introduction: The Royal Marsden began recruiting patients to PRE-
VENTT in April 2014. The trial is a randomised double-blind controlled
phase III study of intravenous ferric carboxymaltose in anaemic patients
undergoing major open abdominal surgery. Amongst the participating
UK centres, The Royal Marsden has recruited the highest number of
patients to date.
Methods: All patients discussed in relevant multidisciplinary team meet-
ings or who attend surgical outpatients are screened for eligibility by our
research nurse. Our electronic patient records (EPR) give access to labo-
ratory results and allow us to easily see if, and when, surgery is planned.
We take consent, randomise and administer the trial medication on the
same day, which often coincides with the patient’s pre-assessment clinic
appointment.
Results: In the first 9 months we recruited 18 patients, the highest num-
ber in the UK. The commonest reason for patients declining to partici-
pate was the perceived burden of the follow-up questionnaires at a time
when many of them would be receiving postoperative chemotherapy.
We frequently identified male patients who were anaemic by the WHO
criteria (Hb less than 130 g/L) but were ineligible for inclusion in the
trial, which initially required Hb 90–120 g/L. The exclusion criteria we
most commonly encounter are blood transfusion in the last 12 weeks and
planned surgery in less than ten days.
Conclusion: We believe our successful recruitment record at The Royal
Marsden is multifactorial, including the presence of a dedicated research
nurse, close collaboration and communication between all members of
the research team and the EPR system. The fact we are a specialist cancer
hospital and therefore have a high incidence of preoperative anaemia is
also significant. The familiarity of the hospital staff with clinical trials
helps us to organise drug administration on the same day as consent
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
36 Abstracts of the 16th Annual NATA Symposium

and randomisation, which reduces the need for inconvenient additional Introduction: Colorectal cancer surgery is frequently followed by post-
hospital appointments. operative anaemia, because of the additive effects of surgical blood
The Hb eligibility criterion has recently been adjusted by the PREVENTT loss and disease-related preoperative anaemia and/or ferropenia. While
Chief Investigator to Hb 90–130 g/L for men, and we anticipate recruit- intravenous iron has shown to be an effective intervention to reduce the
ing more patients as a consequence of this change. number of transfusions in many settings, there are no studies describ-
ing its effectiveness in the management of postoperative anaemia fol-
lowing colorectal cancer surgery. An observational study was done
P58 with the aim of describing the prevalence and the current pattern
of use of iron treatments in patients undergoing colorectal cancer
Case Presentation – Inadvertent Extravasation of Ferric
surgery.
Carboxymaltose (Ferinject) Solution
Methods: Clinical data was retrieved from all patients who under-
M. Thomas, J. Faulds, C. Ralph & S. Staddon went surgery at our hospital for colorectal cancer during 2013, includ-
Royal Cornwall Hospitals NHS Trust, Cornwall, England, UK ing gender, age, type of operation, serum haemoglobin (Hb) level pre
and 30 days post-surgery, number of postoperative transfusions and
Introduction: Use of parenteral iron replacement is becoming increas-
prescription of oral iron at hospital discharge. Data on use of intra-
ingly common in the optimisation of patients for elective major
venous iron therapy was retrieved from the hospital pharmacy invoicing
surgery. Here we discuss a case of a small volume extravasation of par-
database.
enteral iron infusion resulting in significant and likely permanent skin
Results: A total of 160 patients, 66.3% male and with median age 69.9
discolouration.
(38–89) years, were registered during 2013. The most common surgery
Case Report: A 65-year-old male with a background history of
was left colon resection (38.1%) and 57.5% underwent laparoscopic
ischaemic heart disease, cerebrovascular disease and diabetes was
procedures. Pre and post (days 1 and 30) Hb values are shown in table 1.
referred to the local blood conservation service prior to major urologi-
Transfusions were given to 11 patients (6.9%) before hospital discharge,
cal surgery following a finding of iron deficiency anaemia (IDA) in his
and 27.5% of all patients received a mean cumulated dosage of 425 mg
preoperative assessment. He was assessed and listed for intravenous iron
of intravenous iron in the postoperative period. Only 37/72 (51.4%)
replacement therapy in the form of ferric carboxymaltose (Ferinject)
patients with postoperative day 1 Hb <11 g/dL were treated, and only 4
infusion. On the day of infusion a 22 gauge venflon was sited, flushed
(2.5%) patients were prescribed oral iron treatment at the time of hospital
with 0.9% sodium chloride and the Ferinject infusion started. After
discharge.
15 minutes, the patient noticed a small swelling, approximately 1 cm
by 1 cm, associated with brown discoloration at the venflon site. The
infusion was stopped immediately. The patient was contacted routinely
two weeks later as part of local follow up policy. At this time, the patient Haemoglobin
reported the discolouration had become much worse, now spread to concentration (g/dL) Preop Day 1 postop Day 30 postop
an area of approximately 15 cm by 10 cm. Although the patient did not
have any other symptoms, the continued discolouration was alarming. <8 - 6 (3.8%) -
Four months after the event, the brown discoloration of the skin is ≥8 < 9 7 (4.4%) 9 (5.6%) 1 (0.6%)
still present without change to size or colour, raising the possibility of ≥9 < 10 5 (3.1%) 17 (10.6%) 5 (3.1%)
permanent skin discolouration. ≥10 < 11 17 (10.6%) 40 (25%) 10 (6.3%)
Discussion: Patients undergoing elective surgery with undiagnosed ≥11 < 12 35 (21.9%) 35 (21.9%) 22 (13.8%)
anaemia have an increased likelihood of requiring perioperative blood ≥12 < 13 45 (28.1%) 33 (20.6%) 42 (26.3%)
transfusions with increased morbidity and mortality in the periopera- ≥13 50 (31.3%) 17 (10.6%) 39 (24.4%)
tive period. The treatment of IDA before elective surgery, therefore, is
No data 1 (0.01%) 3 (0.02%) 41 (25.6%)
of upmost importance. Ferric carboxymaltose (Ferinject) is an example
Total 160 (100%) 160 (100%) 160 (100%)
of a colloidal iron preparation for the parental treatment of IDA. The
use of Ferinject is becoming increasingly more common. At the Royal
Cornwall Hospitals Trust, there have been over 700 infusions in the
preoperative setting since 2012. Despite product literature for Ferinject
acknowledging permanent skin discolouration following subcutaneous
or venous extravasation, this is the first episode we have seen locally Conclusions: A high prevalence of postoperative anaemia was observed
within our trust and the risk of possible permanent skin discolouration is immediately after and 30 days post colorectal surgery, but postoperative
not routinely discussed with all patients. Although not life-threatening, intravenous iron was given only to 27.5% of patients, and oral iron
this side effect attributable to extravasation may have significant psycho- prescriptions only to 2.5%. There is a need to increase the use of iron
logical impact on some patients. This may be especially important to supplements in the postoperative period.
acknowledge as an increasing number of pregnant patients are supported
through there pregnancy with iron replacement therapy. We present this
case to highlight the possible complications and raise awareness of per- P60
manent skin discolouration following only a very small extravasation Iron Deficiency and Intravenous Iron Therapy after Major
of iron. Cancer Surgery
H. Lawrence, S. Cleland, J. Benham, E. Todman & R. Rao Baikady
The Royal Marsden NHS Foundation Trust, London, UK
P59
Introduction: Anaemia is common in the cancer population and is
Anaemia after Colorectal Cancer Surgery: Prevalence increasingly recognised as being associated with adverse postopera-
and Pattern of Use of Iron Treatments tive outcomes. If iron deficiency is identified it can be treated with
M. J. Laso, A. Vallejo, R. Vives, I. Roig, M. Barquero & C. Pontes total dose intravenous iron in the postoperative period, potentially
Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat reducing the need for blood transfusion and improving quality of life
Autònoma de Barcelona, Spain indices.

Transfusion Medicine, 2015, 25, Suppl. 1, 13–54 © 2015 The Authors

Transfusion Medicine © 2015 British Blood Transfusion Society
 Abstracts of the 16th Annual NATA Symposium 37

Methods: Blood was tested postoperatively for iron, ferritin, total iron clinical protocol allowed the detection and treatment of 13 unknown
binding capacity and transferrin saturation in 89 patients over a 6-month oncologic pathologies.
period (44 females; 45 males). There was a wide mix of surgical cases,
including major upper and lower gastrointestinal, hepatobiliary, and Table 1. Baseline and post-treatment (follow-up) haematimetric and
gynaecological. iron parameters.
Results: Mean preoperative haemoglobin concentration was 121 g/L in
females and 127 g/L in males; 19 (43%) of females and 20 (44%) of Platelets Iron
males were anaemic preoperatively. Mean postoperative haemoglobin Hb Hct MCV MCH (x 103 / (μg/ TSI Ferritin
concentration was 103 g/L in females and 105 g/L in males. 79 (89%) of (g/dL) (%) (fL) (pg) RDW μL) dL) (%) (ng/mL)
patients had postoperative transferrin saturation ≤20%, and of these 36
(92%) females and 38 (95%) males were also anaemic. Ferritin results Baseline 7.8 27 74 24 19 353 28 5 27
were available in 79 patients. True iron deficiency anaemia (defined Follow-up 12.2* 38* 874* 28* 22* 255* 75* 30* 332*
as transferrin saturation ≤20% and ferritin ≤100 ng/ml) was identi-
Hb, haemoglobin; Hct, haematocrit; MCV, mean corpuscular volume; MCH,
fied in 17 (47%) females and 13 (30%) males postoperatively. Func-
mean corpuscular haemoglobin; RDW, red cell distribution width; TSI, transferrin
tional iron deficiency was identified in 16 (44%) females and 24 (56%)
saturation index. *P < 0.01.
males.
Total dose intravenous iron (20 mg/kg iron isomaltoside [Monofer]) was
safely administered to 14 females with iron deficiency anaemia (mean
postoperative haemoglobin 96 g/L) and 11 males (mean postoperative Conclusions: Overall, our data seem to support the feasibility of a
haemoglobin 98 g/L) in the postoperative period when the patients were clinical protocol for classification, treatment and follow-up of patients
progressing well and not on antibiotic therapy. presenting with moderate-to-serve anaemia at the ED. In addition, data
Conclusion: Postoperative iron deficiency anaemia was common in can- also seem to support the efficacy, safety and tolerability of IVI for
cer patients. The distinction between true and functional iron deficiency correcting or improving IDA. Early diagnosis and treatment of IDA at
is potentially confounded by a rise in ferritin as part of the acute phase the ED will most probably result in an improved use of blood products
response. There is a role for treating both true and functional iron defi- at this hospital health-care area.
ciency anaemia with total dose intravenous iron in the postoperative
period.
P62

P61 Intravenous Ferric Carboxymaltose for Iron Deficiency or

Iron Deficiency Anaemia in Pregnancy: An Updated Cohort
Feasibility and Efficacy of a Clinical Protocol Using Study
Intravenous Iron for Treating Iron Deficiency Anaemia at the
B. Froessler1,2 , C. Bunn1 , N. Hodyl3 & G. Dekker4
Emergency Department 1 Department of Anaesthesia, Lyell McEwin Hospital, Elizabeth Vale,
M. Quintana Díaz1 , S. Fabra1 , S. Gómez-Ramirez2 , J.A. García-Erce3 2 Acute Care Medicine, 3 School of Paediatrics and Reproductive Health
& M. Muñoz2
1 Emergency Department, University Hospital La Paz, Madrid; Robinson Research Institute, University of Adelaide, Adelaide,
4 Department of Obstetrics & Gynaecology, Lyell McEwin Hospital,
2 Transfusion Medicine, School of Medicine, University of Málaga,
Elizabeth Vale, South Australia
Málaga, Spain; 3 Haematology, General Hospital San Jorge, Huesca
Introduction: Peri-partum iron deficiency (ID) or iron deficiency
Introduction: Anaemia is a common finding in routine blood exami-
anaemia (IDA) is associated with significant maternal, foetal and infant
nations of patients presenting at the Emergency Department (ED), with
morbidity. Current options for treatment are limited. Oral iron can be
allogeneic blood transfusion and hospitalisation for anaemia classifica-
ineffective or poorly tolerated, and RBC transfusions carry inherent
tion or referral to other health-care area being the usual care pathway. To
risks. Intravenous (IV) ferric carboxymaltose (FCM) is a new treat-
optimise blood product use, we developed a clinical protocol for man-
ment option that may be better tolerated and more effective. We pub-
agement of iron deficiency anaemia (IDA), which includes early anaemia
lished data from 65 pregnant women receiving FCM in pregnancy in
classification, the use of intravenous iron (IVI) and patient’s follow-up at
2014. Since, a further 246 pregnant women had a FCM infusion at our
the ED.
institution.
Method: From November 2010 to November 2014, complete
Methods: Prospective observational study. Data of 311 women was
blood counts, ferritin, and transferrin saturation index [TSI]
combined to assess the safety and efficacy of ID and IDA correction
were requested for patients presenting with anaemia at the ED.
with IV FCM in the 2nd and 3rd trimester of pregnancy. Treatment
Patients with moderate-to-severe IDA (Hb <10 g/dL), who did
effectiveness was assessed by repeat haemoglobin (Hb) measurements.
not required hospitalisation or immediate red blood cell transfu-
Safety was assessed by analysis of adverse effects (AE), foetal heart rate
sion, were attended at the ED high-resolution consulting room.
monitoring during the infusion and newborn outcome data.
These patients received IVI (mostly ferric carboxymaltose), accord-
Results: IV FCM significantly increased Hb values (p < 0.01) above
ing product package insert, and were followed-up for 3 months.
baseline levels. No serious AE were recorded, minor AE occurred in 46
Patients’ characteristics, clinical and laboratory data were prospectively
(14.8%) of women. Foetal heart rate monitoring did not indicate any
collected.
Results: Overall, 148 patients (110 women/38 men; mean age 65 years) negative impact on the foetus. No adverse outcome was noted in the
entered the study. Most frequent causes of IDA were gastro-intestinal neonate.
and gynaecological bleeding. Mean IVI dose was 1600 ± 650 mg per Conclusion: Our updated data consolidates our previously published
patient, and only five mild (headache, urticarial, heartburn, pyrexia, results and is consistent with existing observational reports of the
superficial phlebitis; 3.3%) and one moderate (bronchospasm; 0.7%), safe and effective use of FCM in the treatment of ID and IDA in
self-limited complications (5.5%) were witnessed during the infusion pregnancy.
or the monitoring period. As depicted in Table 1, IVI therapy led to
a mean increase of 4.4 ± 2.0 g/dL in Hb levels, and to normalisation of
haematimetric and iron parameters in most patients. Interestingly, this

© 2015 The Authors Transfusion Medicine, 2015, 25, Suppl. 1, 13–54

Transfusion Medicine © 2015 British Blood Transfusion Society
38 Abstracts of the 16th Annual NATA Symposium

Table 1. Haemoglobin levels (g/L) across the testing period for women in the study, split by severity of iron deficiency anaemia at study enrolment

Haemoglobin levels (g/L)

Gestational age at entry (weeks) Pre-infusion 3 weeks post infusion 6 weeks post infusion post-partum

All women 32 (0.3) 97.92 (0.6) 110.3 (0.7) 116.6 (1) 109.0 (1.9)
n = 311 n = 287 n = 135 n = 97
No anaemia 30 (1.3) 121.8 (1.3) 129.9 (2.3) 113.8 (3.4) 108.4 (8.9)
Hb ≥115 g/L n = 19 n = 17 n=6 n=8
Mild anaemia 33 (0.3) 101.5 (0.4) 111.7 (0.7)* 115.3 (1.3)* 106.9 (2.7)*
Hb ≥95–114 g/L n = 182 n = 162 n = 65 n = 46
Moderate anaemia 34 (0.6) 92.2 (0.2) 105.1 (1.2)* 118.7 (2.6)* 112.8 (4)
Hb 90–94 g/L n = 52 n = 48 n = 20 n = 24
Severe anaemia 33 (0.8) 83.8 (0.6) 104.8 (1.8)* 116.5 (3.0)* 109.9 (3.8)
Hb <90 g/L n = 58 n = 48 n = 22 n = 19

Data are presented as means (SEM). *p < 0.01 compared to pre-infusion haemoglobin levels.

P63
Establishing an Iron Infusion Service in a Specialist Cancer
Treatment Centre
S. Cleland, H. Lawrence, J. Benham, E. Todman & R. Rao Baikady
The Royal Marsden NHS Foundation Trust, London, UK
Introduction: Iron deficiency anaemia is common in patients under-
going major surgery and is associated with adverse perioperative out-
come both in morbidity and mortality. Allogenic blood transfusion,
whilst life-saving in some clinical scenarios, also carries the risk of infec-
tion transmission, transfusion reactions and adverse postoperative out-
comes. In our institution – a specialist cancer hospital – we established
an iron infusion service for the treatment of iron deficiency anaemia
in our surgical population as part of a patient blood management
programme.
Methods: Preoperatively patients were either referred to the iron service
by surgical teams or identified at the preoperative assessment clinic. Iron
deficient patients (transferrin saturation <20%) were offered total-dose
intravenous iron infusion (20 mg/kg iron isomaltoside [Monofer]) in
the preoperative period, administered over 60 minutes, usually in a
chair on our Clinical Assessment Unit. Postoperatively patients admit-
ted to the ITU after major cancer surgery were also tested for iron
deficiency. Patients found to have iron deficiency anaemia were offered
an iron infusion when they were progressing well clinically after their
surgery, and had not received a blood transfusion within the previous
24 hours.
Results: Between January 2012 and May 2014, 77 patients were treated
with total dose intravenous iron infusions – 22 preoperatively and 55
postoperatively. The largest patient group to receive intravenous iron
was those undergoing hepatobiliary surgery (22 patients), followed by
upper gastrointestinal surgery (11), colorectal surgery (8), gynaeco-
logical surgery (7), sarcoma surgery (6), urological surgery (4), head
and neck surgery (3), breast surgery (2) and plastics (1). The mean
haemoglobin increment in patients who received iron preoperatively was
8.3 g/dL over 21 days. 13 of 22 patients went on to have a blood trans-
fusion during their admission. Postoperative patients saw a mean incre-
ment in their haemoglobin of 7 g/dL following IV iron, 14.2 g/dL at 3
weeks, 23.3 g/dL at 4 weeks and 27.5 g/dL at 5 weeks after the treatment.
Iron infusions were well tolerated in all patients with no serious reactions
noted during the series.
Conclusions: The use of total dose intravenous iron for the treatment of
perioperative iron deficiency anaemia is an increasingly utilised com-
ponent of patient blood management in our institution. The limited
increment in preoperative haemoglobin before surgery is likely due to
the limited time between pre-assessment and surgery that many patients
have due to their cancer diagnosis. Postoperative patients have consis-
tently seen significant increments in haemoglobin around the 3-4 week
period following iron infusion.
P64
Comparative Cost-Efficacy of Four Intravenous Iron
Formulations for Treating Inflammatory Bowel Disease
Associated Anaemia: An Estimation from Published Data
S. Gómez-Ramírez1 , J. Pavía2 , E. Martín-Montañez2 & M. Muñoz3
1 InternalMedicine, Xanit International Hospital, Benalmádena, Málaga;
2 Pharmacology and 3 Transfusion Medicine, School of Medicine,
University of Málaga, Málaga, Spain
Introduction: Anaemia is one of the most frequent extra-intestinal
manifestations of inflammatory bowel diseases (IBD), and negatively
impacts patient’s quality of life. Many patients will respond to oral iron,
but compliance may be poor, whereas intravenous iron (IVI) compounds
provide a faster Hb increase and iron store repletion, and present a
lower rate of treatment discontinuation. We comparatively estimated the
cost-efficacy of an 8-week treatment course, pooling data of four different
IVI compounds from five recent studies (1-5).
Methods: The efficacy of iron sucrose (IS), ferric carboxymaltose (FCM),
iron isomaltoside-1000 (MNF), and low molecular weight iron dextran
(LMWID) was estimated as the difference (ΔHb g/dL) Hb values at week
8 and at baseline. Cost calculation per patient was performed from a
Spanish perspective, taking into account: 1) the cost of IVI, 2) direct
hospital costs (personnel, infusion material, infusion and observation
time) and 3) indirect hospital costs (the general functioning costs) (6).To
correct for a possible effect of the different IVI doses administered, the
cost per 1 Δg/dL Hb was also calculated.
Results: At week 8, ΔHb was 2.2 g/dL for IS, 3.1 g/dL for FCM, 2.6 g/dL
for MNF, and 2.0 for LMWID. Mean IVI doses were 1130, 1390, 885,
and 949 mg, respectively, and ΔHb/g IVI were 1.9, 2.2, 2.9, and 2.1 g/dL,
respectively. As depicted in Table 1, mean treatment cost both per patient
and per Δ 1 g/dL Hb were higher for IS when compared to FCM, MNF
and LMWID.
Conclusion: The four IVI formulations were efficacious at cor-
recting anaemia, with ΔHb showing an apparent dose-response
pattern. However, FCM, MNF and LMWID allow for giving up to
1000–1500 mg in a single session, thus facilitating patient management
and reducing treatment costs when compared to IS. Head-to-head
prospective cost-efficacy comparisons of these IVI formulations are
needed.

Transfusion Medicine, 2015, 25, Suppl. 1, 13–54 © 2015 The Authors

Transfusion Medicine © 2015 British Blood Transfusion Society
 Abstracts of the 16th Annual NATA Symposium 39

Table 1.

IS1,2 FCM2,3 MNF4 LMWID5

Patients 284 376 219 33

Hb at baseline (g/dL) 10.3 9.6 9.6 9.3
Hb at week 8 (g/dL) 12.5 12.7 12.2 11.3
ΔHb (g/dL) 2.2 3.1 2.6 2.0
IVI dose per patient (mg) 1130 1390 885 949
IVI dose per session (mg) 200 200–1000 200–1000 20 mg/kg
Infusion + observation (min) 75 45 60 180
Sessions per patient 5.6 2.0 1.8 1.0
IVI cost per 100 mg (€) 8.5 20 20 10.3
Administration cost per session6
Personnel 22.5 13.5 18.0 54.0
Materials 7.0 7.0 7.0 7.0
Others 17.5 14.5 16.0 28.0
Treatment cost per patient (€) 359 348 251 187
Treatment cost per Δ 1 g/dL Hb (€) 163 112 97 93

REFERENCES
1. Lindgren et al. Scand J Gastroenterol 2009;44: 838-45
2. Evstatiev et al. Gastroenterology 2011;141:846-853.e1-2
3. Kulnigg et al. Am J Gastroenterol 2008;103:1182-92
4. Reinisch et al. Am J Gastroenterol 2013;108:1877-88
5. Khalil et al. Eur J Gastroenterol Hepatol 2011;23:1029-35
6. Calvet X et al. PLOSone 2012;7:e45604.

© 2015 The Authors Transfusion Medicine, 2015, 25, Suppl. 1, 13–54

Transfusion Medicine © 2015 British Blood Transfusion Society
40 Abstracts of the 16th Annual NATA Symposium
FLUID THERAPY/OXYGEN CARRIERS
P65
Cerebrovascular Response to Infusion of EAF P5K6-Alb, NO
Producing, Colloidal Plasma Volume Expander, is Muted
in Transgenic Mouse Models of Sickle Cell Disease
C. A. Branch, M.-H. Cui, H. Billet & S. Acharya
Albert Einstein College of Medicine, Bronx, NY, USA
Introduction: Sickle cell disease (SCD) is essentially a disease of blood
flow impairment. Extension Arm Facilitated (EAF) P5K6 Alb (PEG Alb),
a semisynthetic supra-perfusion resuscitation fluid, has been demon-
strated to improve blood flow and haemodynamics in transgenic mouse
models of SCD as reflected by intravital microscopy. PEG Alb increases
perfusion by a combination of vasodilator effects and increased func-
tional capillary density; tissue oxygenation is improved without increas-
ing oxygen carrying capacity. Accordingly, PEG Alb has been advanced
as a novel therapeutic molecule for SCD. In the present study the cere-
brovascular response to a top load IV infusion of PEG Alb was investi-
gated in two transgenic mouse models of SCD by MRI.
Methods: MRI was performed at 9.4 T (Agilent Inc.) under isoflurane
anaesthesia. Transgenic S + S Antilles mice (mild sickle cell pathology
without anaemia) and Berkley mice (severe sickle cell disease with
anaemia) were compared to wild type C57BL (WT) mice pre- and
post- a 10% IV top load of PEG Alb. We measured cerebral blood flow
(CBF) and used fMRI- based Blood Oxygen Level Dependent (BOLD)
Response to a brief period of HyperOxia (BOLD-RHO) as an index of
deoxy-haemoglobin (deoxy-Hb) concentration in the brain. Diffusion
Imaging was used to assess brain mean diffusivity (MD) of water as a
measure of brain inflammation.
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
Results: Base-line CBF is significantly elevated in S + S Antilles mice and
in Berkley mice by 143% and 210%, respectively, compared to WT. A
10% top-load IV infusion of PEG Alb increased CBF in WT mice by
nearly 130% and lasts up to a period of 72 hrs (p < 0.05). Conversely
PEG-Alb decreased CBF in both S + S Antilles and Berkley mice to ∼90%
of baseline, respectively. Thus CBF in PEG Alb transfused S + S Antilles
was comparable to that in transfused WT, while Berkley flow remained
much higher than in treated WT, even after 72 hrs. After top loading,
BOLD-RHO response was reduced in WT, while in S + S Antilles no
change in BOLD-RHO was observed. In contrast, PEG Alb increased the
BOLD-RHO response in Berkley mice. MD was unchanged in WT and
S + S Antilles mice after top load, but increased mildly in Berkley mice
(p < 0.05).
Conclusions: After infusion of PEG Alb, CBF increases in WT mice
while in SCD mice the response to PEG Alb is essentially muted.
Increased CBF in the WT is accompanied by a decreased BOLD
response, as increased O2 delivery results in decreased deoxy-Hb levels.
In S + S Antilles mice, the CBF response to PEG Alb infusion is min-
imal and deoxy-HB concentration remains unchanged. In the Berkley
mouse, PEG Alb decreased CBF, and increased deoxy-Hb concentration,
while MD increased suggesting increased inflammation. These findings
suggests that the hyperemic CBF in Berkley is not adequate to meet
metabolic demand, consistent with the hypothesis that CBF in SCD may
already be maximally adjusted through autoregulatory mechanisms in
order to satisfy cerebral oxygen demand. Combining PEG Alb ther-
apy with antioxidant therapy may attenuate the inflammation seen in
Berkley mice.
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

HAEMOSTASIS & THROMBOSIS
P66
Lineal Multiple Regression Model to Predict Intraoperative
Blood Loss during Paediatric Orthotopic Liver
Transplantation
J. De Vicente, A. Perez-Ferrer, G. Campo, R. Perez-Gonzalez
& F. Gilsanz
La Paz Paediatric University Hospital, Madrid, Spain
Introduction: Intraoperative haemorrhage is a major concern during
paediatric orthotopic liver transplantation (OLT). Although anaesthetic
perioperative management, surgical procedures and graft preservation
techniques have improved importantly, and blood transfusion require-
ments have decreased accordingly, intraoperative blood loss continue to
be highly variable. As patients in whom large amount of blood is needed
have reported worse graft function, higher infection rate and gastroin-
testinal complications, to identify patients at high risk of intraoperative
massive haemorrhage may be of huge interest.
Methods: Observational descriptive study approved by the Ethics
Research Committee of our institution of 43 consecutive paediatric
patients (ages 3 months – 16 years) who underwent OLT. Demographic,
clinical and analytical variables of these patients were recorded. As a
predictive lineal regression model is intended, we used Mallow’s Cp to
find the best model involving a subset of these predictors.
Results: According with Mallow’s Cp value, the final lineal regres-
sion model selected included the next variables: presence of clinically
detectable ascites (yes/no), previous abdominal surgery procedure
(yes/no), duration of surgery (hours), baseline fibrinogen (mg/dl), recep-
tor weight (kg) and baseline platelets count (x10^3/mcl). We entered
these predictors in a lineal regression model, to estimate blood loss
during paediatric OLT. The resulting equation is: Estimated Blood Loss
(ml) = 1172.8 + 392 x ascites + 515 x previous abdominal surgery + 96.5
× duration of surgery – 2,0 x fibrinogen + 53 × weight – 0.6
x baseline platelets count (F = 38.957, degrees of freedom = 6,
p = 0.001).
Conclusion: Intraoperative blood loss during paediatric OLT can be
predicted accurately (r = 0.69) with a subset of six variables: presence
of clinically detectable ascites (yes/no), previous abdominal surgery
procedure (yes/no), duration of surgery (hours), baseline fibrino-
gen value (mg/dL), receptor weight (kg) and baseline platelets count
(x103 /μL).
P67
The Effect of Intraoperative Low Dose Epinephrine Infusion
on Bleeding during Total Hip Arthroplasty – A
Double-blinded Placebo-controlled Randomised Trial
O. Jans1 , U. Grevstad2 , H. Mandøe3 , H. Kehlet1 & P. I. Johansson4
1 Section
for Surgical Pathophysiology, Rigshospitalet, Copenhagen,
Denmark; 2 Department of Anaesthesia, Gentofte Hospital, Gentofte,
Denmark; 3 Department of Anaesthesia, Vejle Hospital, Vejle, Denmark;
4 Department for Transfusion Medicine, Rigshospitalet, Copenhagen,
Denmark
Introduction: Total hip arthroplasty (THA) is associated with both
intraoperative blood loss and postoperative oozing resulting in anaemia
and, in a subset of patients, transfusion of red blood cells. Administration
of epinephrine causes activation of the coagulation system via several
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 41
different mechanisms. Therefore we aimed to evaluate if intraoperative
low dose infusion of epinephrine reduced intraoperative- and early
postoperative blood loss in THA.
Methods: After consent, 106 patients scheduled for THA under spinal
anaesthesia were randomly assigned to receive an infusion of either
epinephrine 0.05 μg/kg/min or placebo (normal saline) during the entire
surgical procedure. The primary outcome was intraoperative blood loss
directly measured by drains and weighing swabs. The secondary out-
come was total blood loss at 24 h postoperatively calculated using the
Gross formula. The study was conducted in accordance with the Good
Clinical Practice guidelines.
Results: Of the 106 patients randomised, 6 patients were excluded due
to conversion to general anaesthesia leaving 100 patients for analyses.
The mean duration of surgery was 60 (SD 21) minutes. Intraoperative
blood loss was 343 (95% CI 300–386) mL in the epinephrine group vs.
385 (353–434) mL in the placebo group (p = 0.23). 24-h blood loss was
902 (800–1004) mL in the epinephrine group vs. 1081 (946–1215) mL
in the placebo group (p < 0.05).
Conclusion: Intraoperative low dose epinephrine infusion did not sig-
nificantly reduce intraoperative blood loss in THA compared to placebo.
However a significant 17% reduction in 24-h blood loss was found in the
epinephrine group compared to placebo. Further studies evaluating low
dose epinephrine in patients with high risk of significant bleeding are
warranted.
P68
Multicentre, Randomised Placebo-Controlled Clinical Trial
to Evaluate the Effect of Perioperative Use of Tranexamic
Acid on Transfusion Requirements and Surgical Bleeding
in Major Spine Surgery
L. Mora1 , M. J. Colomina1 , E. Ciércoles1 , E. Guerrero1 , I. Otero2 ,
A. Pi2 , M. Basora3 & C. Garcia4
1 Anaesthesia Department, Hospital Universitari Vall d’Hebron,
Barcelona, Spain; 2 Anaesthesia Department, Hospital Universitari
Bellvitge, Barcelona, Spain; 3 Anaesthesia Department, Hospital Clínic,
Barcelona, Spain; 4 Anaesthesia Department, Hospital de Getafe, Madrid,
Spain
Background and Goal of Study: Our objective was to determine the
efficacy and safety of intraoperative tranexamic acid (TXA) and placebo
at reducing perioperative blood loss and the transfusion rate in adult
patients submitted to major spinal surgery.
Methods/Design: Prospective, randomised, double-blinded control
study to evaluate the effects of TXA and placebo (saline solution) in
complex spinal surgery. Efficacy will be determined by intraoperative
and postoperative blood loss. Other clinical outcomes include trans-
fusion rates, length of hospital stay and the safety profile of TXA in
the postoperative period and at mid-term follow-up (± 6 weeks). Main
comparisons were performed using mixed models with logtransformed
values of intraoperative and total bleeding, adjusted by age, BMI,
number of fusion levels, and decompression.
Results: Ninety five patients were randomised. 44 patients (29 females,
mean age of 59 years) received TXA acid and 51 (38 females, mean
age of 50 years) received saline solution. TXA acid reduced intraoper-
ative (869.17 vs. 1228.80; p = 0.021) and total blood losses (1591.69 vs.
2052.33; p = 0.034) compared with saline solution. 21 (47.7%) patients of
TXA group did not require any transfusion compared to control group,
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
42 Abstracts of the 16th Annual NATA Symposium

17 (33.3%) p = 0.056. The average number of units transfused was 1.14 P69 Table
in TXA group and 2.05 units in control group. There was no difference
with duration of surgery, levels fused, decompression and hospital stay. NS TA P value
2 patients in TXA group and 1 patient in control group presented an
episode of DVT. Preoperative Hb (g/L) 132 ± 16 131 ± 18 0.7815
Discussion & Conclusion: TXA significantly reduced blood loss and Postoperative Hb (g/L) 96 ± 15 98 ± 14 0.6891
blood transfusion requirements in patients undergoing major spinal
Transfused patients 28/49 pts 26/49 pts 0.8391
surgery, showed an acceptable safety profile and did not appear to
Total RBC units per group 86 52
increase the risk of DVT.
Trial Registration: ClinicalTrials.gov ID: NCT01136590 RBC units per transfused 2 (2, 4) 2 (1, 2) 0.0252
Grant: Project Funded by the Ministry of Health and Social Policy - patient
Department of Advanced Therapies and Transplantation (DGTATX) - Total FFP units per group 14 7
Order SAS/2481/2009. Total Plt units per group 4 0
Total blood products per 2 (2, 4) 2 (1, 2.75) 0.0402
REFERENCES transfused patient

1. Huang F, Wu D, Ma G, Yin Z, Wang Q. The use of tranexamic acid NS = normal saline (placebo group); RBC = red blood cell; FFP = fresh
to reduce blood loss and transfusion in major orthopedic surgery: a frozen plasma; Plt = platelets; values presented as numbers or median
meta-analysis. J Surg Res 2014;186:318-27. (interquartile range)
2. Verma K, Errico T, Diefenbach C, et al. The relative efficacy of antifib-
rinolytics in adolescent idiopathic scoliosis: a prospective randomized
trial. J Bone Joint Surg Am 2014;96:e80.
P70

P69
Tranexamic Acid Reduces Transfusion Requirements
in Adult Major Spine Surgery
J.-F. Hardy, Q. Wu, V. Brulotte, D. Boudreault, M. Ruel
& P. Bodson-Clermont
Department of Anesthesiology and Research Center of the CHUM,
Montreal, Quebec, Canada
Introduction: The efficacy of tranexamic acid (TA) in adult major spine
surgery has not been clearly demonstrated. Low-dose TA reduces bleed-
ing (an intermediate outcome) but not transfusion requirements (Wong
J et al. Anesth Analg 2008;107:1479). Higher (vs. lower) doses of TA
have been shown to be more efficacious in children (Grant JA et al.
J Pediatr Orthop 2009;29:300) and in major orthopedic surgery (Zuf-
ferey P et al. Anesthesiology 2006;105:1034). We investigated the effi-
cacy of high-dose TA to reduce transfusion requirements in major spine
surgery.
Methods: This double-blind, randomised and placebo-controlled study
was approved by the Ethics’ committee and patients provided informed
consent. 99 adult patients undergoing major spine surgery at risk of
bleeding (neoplasia/multilevel) were included. Patients received TA
(30 mg/kg bolus + 16 mg/kg/hr infusion) or an equal volume of normal
saline (NS) up to 6 h after the end of surgery. Primary outcomes were
the incidence of transfusions and, in transfused patients, the number of
units transfused. TEG (control + every 2 h) were obtained in the first 30
patients.
Results: One patient was excluded in the TA group (surgery included
additional lung and thoracic resection). The incidence of transfusions
was the same in both groups (TA 53% vs. NS 57%) while transfu-
sion requirements were decreased in those pts transfused. Postoperative
bleeding was decreased in the TA group (265 mL (0, 505) vs. 600 mL
(340, 865); p = 0.0002). At the end of surgery D-dimers were signifi-
cantly lower in the TA (340 (217, 655) vs. the NS group 3730 (2500,
5110); p < 0.001) but TEG variables (R, K, alpha angle, MA, LY60) were
the same in both groups. The incidence of adverse events was similar in
both groups. There was no evidence of DVT by lower extremity Doppler
examination in any patient.
Conclusion: We have shown that, as in cardiac surgery (Sigaut S et al.
Anesthesiology 2014;120:590), high-dose TA does not reduce the inci-
dence of transfusion while it effectively reduces transfusion requirements
and postoperative bleeding in major spine surgery. High-dose TA was
safe in our limited number of patients.
Abstract withdrawn
P71
Maximal Amplitude Measured by Thromboelastography
(TEG®) May Be a Better Predictor of Bleeding Than Total
Platelet Count in Haematological Malignancy Patients
with Thrombocytopenia: A Pilot Observational Study
R. Kasivisvanathan1 , M. Koutra1 , M. Rooms1 , E. Black1 , L. Desai1 ,
S. V. Mallett2 & R. Rao Baikidy1
1 Department of Anaesthesia, The Royal Marsden NHS Foundation Trust,
London, UK; 2 Department of Anaesthesia, The Royal Free NHS
Foundation Trust, London, UK
Introduction: One of the commonest reason for platelet transfusion in
medical institutions is for prophylaxis against bleeding in patients with
haematological malignancies (HM). Decisions to transfuse platelets are
usually based on total platelet count (TPC). TPC may however inade-
quately predict bleeding in thrombocytopenic patients with haemato-
logical malignancies (HM). This is the first study to evaluate whether
maximal amplitude (MA) measured by Thromboelastography® (TEG®)
is better than TPC at predicting bleeding in thrombocytopenic HM
patients.
Methods: Thirty consecutive adult patients with HM and throm-
bocytopenia (TPC ≤30 × 109 /L) were followed up for 72 hours for
clinically significant bleeding, defined as World Health Organisa-
tion (WHO) grade ≥2 bleeding episodes. Total Platelet count (TPC),
TEG® parameters, Functional Fibrinogen (FF) levels, Activated Par-
tial Thromboplastin time (APTT) and Prothrombin Time (PT) were
measured at inclusion, 12 and 24 hours.
Results: Five out of the 30 patients had clinically significant bleeding
episodes; four patients had WHO grade two bleeding episodes and one
patient had a WHO three bleeding episode. There were no significant dif-
ferences in TPC, APTT or PT between patients having clinically signifi-
cant bleeding and those not. There were however significant differences
in all TEG® parameters including lower FF levels in patients having
clinically significant bleeding 143 mg/dL versus 220 mg/dL in patients
not having clinically significant bleeding. Maximal amplitude was better
than TPC in predicting bleeding with an area under the curve (AUC) for
MA of 0.76, 95% confidence intervals (C.I) 0.54 to 0.92 at the optimal
cut-point there was a 93.33% (95% C.I 65.05% − 99.83%) sensitivity and
53.33% specificity (95% C.I 26.59% −78.7%) with a positive predictive

Transfusion Medicine, 2015, 25, Suppl. 1, 13–54 © 2015 The Authors

Transfusion Medicine © 2015 British Blood Transfusion Society

valve (PPV) of 66.67% (95% C.I 43.98 to 85.89%) and a negative pre-
dictive value (NPV) of 88.89% (95% 51.74 to 98.16%). For TPC AUC
was 0.5778 (95% C.I 0.3688 to 0.7868) at the optimal cut point there was
26.67% (95% C.I 7.95 to 55.09%) sensitivity and 53.33% (95% C.I 26.27
to 78.41%) specificity with a PPV 36.36% (95% CI 11.15 to 69.12%) and
a NPV of 42.11% (95% C.I 20.30 to 66.47%).
Conclusions: Maximal amplitude measured by TEG® may be better
than TPC at predicting bleeding in HM patients with thrombocytopenia.
P72
Thromboelastometry (ROTEM)-guided Diagnosis
and Therapy of Coagulopathy Reduces Fresh Frozen Plasma
Consumption Compared with Prothrombin Time–INR
M. Durila1 , P. Lukáš1 , M. Astraverkhava1 , J. Beroušek1 , E. Linhartová2
& T. Vymazal1
1 Department of Anaesthesiology and Intensive Care Medicine, 2 Blood
Bank Department, Second Faculty of Medicine, Charles University
in Prague, Motol University Hospital, Prague, Czech Republic
Introduction: Standard coagulation tests such as prothrombin time
(PT–INR) is often increased in intensive care unit (ICU) patients and in
practice fresh frozen plasma (FFP) is often administered before surgical
interventions preventively. However, ROTEM as a global test gives infor-
mation about coagulation taking also into account the role of platelets
and fibrinogen. That is why it can give normal results despite an increased
PT–INR. We investigated whether this method can reduce consump-
tion of FFP and whether surgical procedures can be performed safely if
ROTEM is normal despite an increased value of PT–INR.
Methods: We compared the consumption of FFP units in our depart-
ment from the time period before using ROTEM (from June 15, 2012
to March 15, 2013) and after using ROTEM (from March 15, 2014 to
December 1, 2014). ROTEM was used when PT–INR was increased over
1.2 (1.2–2.4) in patients undergoing surgical intervention.
Results: The consumption of FFP during nine months without ROTEM
was 6222 units and from the time when ROTEM was used the con-
sumption of FFP decreased to 4434 units. No bleeding complication was
noticed when ROTEM was in normal range despite the increased value
of PT–INR.
Conclusion: ROTEM is better in assessment of coagulation profile in
ICU patients compared to PT–INR and surgical interventions can be
safely performed in case of normal ROTEM results despite an increased
PT–INR. This reduces the consumption of FFP and results in substantial
cost savings.
Acknowledgments: The project was supported by projects of Min-
istry of Health for conceptual development research organization (No.
00064203) Motol Hospital and by Charles University Grant Agency
No.1318514.
P73
Acute Coagulopathic Bleeding in Perioperative Setting:
Development of an Interventional Algorithm
M. Gomes1 , A. Rodrigues2 , M. Carvalho3 , A. Carrilho4 , A. Robalo
Nunes5 , R. Orfão6 , A. Alves7 , J. Aguiar8 & M. Manuel Campos9
1 SIH, HHTMM, Lisboa, Portugal; 2 S.Imuno-Hemoterapia(IH), H. Sta
Maria (HSM), CHLN, Lisboa, Portugal; 3 SIH, H. S. João, CHSJ, Porto,
Portugal; 4 S. Anestesia (SA), H. S. José, CHLC, Lisboa, Portugal; 5 SIH,
H. P. Valente, CHLN, Lisboa, Portugal; 6 SA, CHUC, Coimbra, Portugal;
7 SA, HSM, CHLN, Lisboa, Portugal; 8 SA, H. Sto António (HSA), CHP,
Porto, Portugal; 9 S. Hematologia Clinica, HSA, CHP, Porto, Portugal
Introduction: There is a clear benefit on the utilisation of strategies
that allow the rapid and ideally directed correction of coagulopathy in
patients (pts) with acute bleeding (AB). Several studies showed that this
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 43
strategy results in the reduction of: blood loss, transfusion requirements
of allogenic components, mortality rates and complications, when com-
pared with the conventional approach.
Aim: With the goal of improving transfusions practices and improve
the pts’ outcomes an interventional algorithm in perioperative setting
was developed by a group of specialist in immuno-haemotherapy and
anaesthesia (Share Network Group = SNG).
Methods: In a meeting in October 30, 2012, the SNG decided to
develop an interventional algorithm for the control of coagulopathic
bleeding (CB) in perioperative setting. Bibliographic references were
obtained by searching in PubMed without date limitations and including
key-words together such as “perioperative bleeding”, “algorithm devel-
opment”, “blood management”, “coagulation”, “haemorrhage”, “transfu-
sion”, “goal-directed therapy”, among others. From the references, were
included those with interest and still actual. The experience of daily prac-
tice of all specialists also contributed to the final consensus.
Results: The interventional algorithm of CB in perioperative setting
developed by the SNG was published online on 25 November 2014 in
Clin Appl Thromb Hemost (DOI: 10.1177/ 1076029614559773).
Discussion: After mechanical control of bleeding the haemostatic ther-
apy should be initiated as early as possible. The rapid detection of pts’
haemostatic state is recommended in order to early correct the missing
components. The administration of tranexamic acid, fibrinogen concen-
trate, platelets and others should follow a logic sequence guided either by
laboratory (classic and/or point-of-care tests) and clinical signs, allow-
ing treatment to be tailored to patient’s needs. If not possible, the clinical
criteria for the suspicion of these deficits should be considered.
Conclusion: The development of interventional algorithm in severe
bleeding is a key action for the rationalisation of blood components
transfusions. In order to optimise its use and applicability, these algo-
rithms should consider the characteristics of each hospital and should be
implemented along with local educational programs. Currently the SNG
is spreading his message throughout the different Portuguese hospitals
by clinical sessions. The use of this algorithm and its impact in hospitals
should be evaluated in a future analysis.
P74
Transfusion Practices and Outcomes of Massive Blood Loss
during Oncosurgery in a Tertiary Cancer Hospital
N. Amin, V. Agarwal & V. P. Patil
Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Mumbai,
India
Objective: Cancer patients undergoing surgery are at increased risk of
receiving massive blood transfusions. In these patients massive blood
loss may be anticipated or unanticipated. Massive blood transfusions
have been associated with increased morbidity and mortality. This is
an audit on all patients who have had massive blood loss during onco-
surgery in a tertiary cancer hospital. The aim of this audit was to study
morbidity and mortality outcomes and the transfusion practices during
massive blood loss.
Design: Retrospective analysis of prospectively maintained data.
Patients: All patients’ children as well as adults who had massive blood
loss during oncosurgery conducted from August 2008 till December
2013 have been included in the study. Massive blood loss was defined
as blood loss more than 1 blood volume in 24 hrs. Study was approved
by hospital Ethics committee.
Measurements: Patient demographic data, duration of surgery, esti-
mated blood loss EBL), intraoperative fluids, blood and blood prod-
uct administered, duration of mechanical ventilation, hospital and ICU
stay, postoperative complications and mortality were recorded. Risk fac-
tors predicting mortality and complications following massive blood loss
were analysed using multivariate logistic regression.
Results: Of 219 patients, 36% had unanticipated massive blood loss.
40% cases were from orthopaedic services. The median blood loss was
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
44 Abstracts of the 16th Annual NATA Symposium
5 litres (0.7–33 litres), i.e. 1.4 times blood volume (1-11.8). Median
duration of ICU stay was 1day (0–32 days) and hospital stay was 12
days (0–164). 36% patients needed to be started on vasopressors for
hypotension and 3 patients had intraoperative cardiac arrest. Patients
who needed vasopressors had blood loss exceeding 1.5 times blood
volume (p = 0.004). In 5% patients the transfusion ratio was 1:1:1 and
in 29% patients it was 2:1:0. 82% patients did not receive platelets in
the intraoperative period. They had a median blood loss of 1.2 (1–5).
3% of these patients needed re-exploration for bleeding. 76% patients
needed postoperative ventilation and the median duration of ventilation
was 14 hours (0.3–504). 23% and 48% patients had respiratory and
cardiac complications respectively. 64% patients received starches in
the intraoperative period. There was no association between the use of
starches or vasopressors and postoperative renal dysfunction. Mortality
following massive blood loss was 5% in children and 9% in adults. 3%
died within 24 hours. Ratio for transfusion was used in only 5% of
patients and ratio was used in 29% patients.
Conclusion: Mortality data following massive transfusions is mostly
reported in trauma patients (8.9–21%). Our hospital and ICU mortality
following massive blood loss is 9.6% and 8.7% respectively. Most of
the deaths were the consequence of uncontrolled tumour bleed. Use
of starches or vasopressors was not associated with postoperative renal
dysfunction.
P75
Validation of Multiplate® Impedance Aggregometry
and Evaluation of Local Reference Values
J. Dhillon, L. Oomen, A. Ahmed & H. Qureshi
Department of Transfusion Medicine, University Hospitals of Leicester
NHS Trust, Glenfield Hospital Leicester, UK
Introduction: Complex cardiac surgery is associated with significant
postoperative blood loss and frequent use of blood components. Patients
on anti-platelet therapy are at greater risk of intra- and postoperative
bleeding. Platelet function tests can be used for evaluation and man-
agement of bleeding in such patients. Multiple Electrode Aggregome-
try (MEA) technique offers rapid platelet function testing using whole
blood, and is being increasingly used as a point of care test. In our institu-
tion, we chose to implement a laboratory based service for platelet func-
tion testing, using the Multiplate® impedance aggregometry technology.
We present data from our evaluation study to establish local reference
ranges and to determine inter-assay and inter-analyser variation, using
two Multiplate® analysers.
Methods: We analysed platelet aggregation by MEA in 33 healthy adult
volunteers. Whole venous blood samples in hirudin (0.045 mg r-hirudin
/ml blood) were used for platelet aggregation using single-use test cells,
each with two independent impedance sensors. MEA was performed
within 1.5 hours after blood collection; 300 μl of saline and 300 μl of
r-hirudin whole blood was added to the test cell, incubated at 37 ∘ C
for 3 minutes. We performed three test procedures, in duplicate for
each analyser, using three different agonists for each specimen: ASPI test
(adenosine diphosphate, 6.5 𝜇M), ASPI test (arachidonic acid, 0.5 mM)
and TRAP test (thrombin receptor activating peptide, TRAP-6, 32 𝜇M).
Data was collected for both analysers using a standard data set in order to
evaluate the inter-assay and inter-analyser variations for the ADP, ASPI
and TRAP assays.
Results: The median AUC (area under curve) and 5th and 95th centiles
for each assay were used to determine a local reference range; ADP assay
(66–113), ASPI assay (84–136) and TRAP assay (99–166). An increased
aggregation was observed on the 5∘ centile for ADP assay compared
to the manufacturers recommended reference range. The inter-assay
coefficient of variation (CV) for the ADP assay (1.04%), ASPI assay
(1.98%) and TRAP assay (1.91%) were found to show good correlation
for each of the two analysers evaluated. However, the inter-analyser
correlation was found to be relatively weak for the TRAP assay (r2 0.57)
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
but considered adequate for the ADP and ASPI assays (r2 0.76 and 0.74
respectively).
Conclusion: Our study highlights the importance of carrying out appro-
priate validation of MEA analysers taking into account the pre-analytical
and analytical variables, and of establishing local reference ranges prior
to using such technology for performing clinical tests, even if the anal-
ysers are to be used in clinical areas as point of care test devices rather
than a laboratory based service.
P76
Introduction of a Platelet Mapping Service May Reduce
Inappropriate Platelet Transfusion in Cardiac Surgery
K. Abass1 , C. Sathananthan2 , J. van der Kaaij1 , & D. Farrar1
1 Department of Anaesthesia, The Heart Hospital, University College
London Hospitals NHS Foundation Trust, London, UK; 2 Department
of Anaesthesia, University, College London Hospitals NHS Foundation
Trust, London, UK
Introduction: Cardiac surgery is associated with a high incidence of
blood product usage. Platelets are frequently administered when platelet
activity is inhibited by antiplatelet medications (clopidogrel and aspirin).
The response to antiplatelet therapy is variable and unpredictable1,2 ,
therefore the decision to transfuse platelets is often made on an empirical
basis. Point of care (POC) tests such as Thromboelastography (TEG®)
masks the effect of these agents. TEG® Platelet Mapping (PLM) is
a POC test that indicates the degree to which platelet function has
been inhibited and may be useful to target platelet transfusion more
appropriately3 . We introduced PLM to our surgical unit to reduce the
risk of inappropriate platelet administration and audited the service.
Methods: Theatre staff were trained to perform PLM and clinicians
educated and supported in its use and interpretation. We aimed to do
PLM in all patients continuing platelet blockers prior to surgery. Blood
product usage was audited at the introduction of the service (baseline
audit of all cardiac cases in September 2012) and after the service was
established (re-audit of all cardiac cases in March 2014). We aimed to
ascertain whether the test was being performed when indicated and
whether this influenced perioperative platelet usage.
Results: There were 77 cases in the baseline audit (70% elective and 30%
urgent/emergency surgery). 38/77 (49%) patients were on anti-platelet
therapy (clopidogrel, aspirin or dual therapy). 19/38 patients received
platelet transfusions. In the re-audit there were 88 patients (68% elective
and 32% urgent or emergency surgery). Twenty one patients were eligible
for platelet mapping. 9/21 (42%) actually underwent PLM and demon-
strated a wide range of residual platelet inhibition (16–93% residual
platelet blockade). In the group of patients who received platelet map-
ping, 3/9 (33%) received platelets (all appropriate). In comparison, 6/12
(50%) patients who did not undergo PLM received platelets.
Conclusion: We have instituted a service to guide platelet transfu-
sions in surgical patients that have had recent anti-platelet therapy in
order to minimize the risk of inappropriate platelet use. The response
to antiplatelet therapy is variable and unpredictable and therefore all
patients on anti-platelet therapy require PLM. We were able to do PLM
for 42% of our patients after rigorous staff training and education.
Although our service is in its infancy, our re-audit suggests that we may
be able to reduce our platelet usage and apply a more targeted approach
in the setting of anti-platelet drugs and cardiac surgery.
REFERENCES
1. Krasopoulos G, Brister SJ, Beattie WS, Buchanan MR. Aspirin “resis-
tance” and risk of cardiovascular morbidity: systematic review and
meta-analysis. BMJ 2008;336:195-8.
2. Snoep JD, Hovens MM, Eikenboom JC, van der Bom JG, Jukema JW,
Huisman MV. Clopidogrel nonresponsiveness in patients undergoing
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

percutaneous coronary intervention with stenting: a systematic review
and meta-analysis. Am Heart J 2007;154:221-31.
3. Janssen PW, ten Berg JM, Hackeng CM. The use of platelet function
testing in PCI and CABG patients. Blood Rev 2014;28:109-21.
P77
Fibrinogen Concentrate Administration during Complex
Cardiac Surgery: Results from the São João University
Hospital during 2014
L. Gonçalves1 , A. Freixo1 , H. Gomes1 , C. Vaz1 , F. Vasconcelos1 , J.
Casanova2 & F. Araújo1
1 Transfusion Medicine Department and 2 Cardiac Surgery Department,
São João University Hospital, Porto, Portugal
Introduction: Complex cardiac surgeries are frequently associated with
coagulopathy and peri- and postoperative severe bleeding, leading to
increased blood transfusion and adverse outcomes. Coagulopathy is
multifactorial, however, it is known that changes in levels and function of
fibrinogen play a crucial role. Fibrinogen concentrates (FI) are increas-
ingly being used to control coagulopathy and bleeding in these patients,
reducing the need for allogeneic blood products.
Methods: We retrospectively analysed the effect of FI administration
in 26 consecutive patients (17 males, 9 females, with a median age
of 69.2 years) undergoing complex cardiac surgeries who had severe
non-surgical perioperative bleeding. We compared the number of allo-
geneic blood products (red blood cells-RBC, fresh frozen plasma-FFP,
and platelets, PLT) before and after FI administration. Laboratory coag-
ulation tests, including thromboelastometry, were performed to guide
administration of all products.
Results: The mean plasma fibrinogen levels measured by Clauss method
was 148 mg/dL before administration of fibrinogen concentrates, though
all the patients had MCF-Fibtem <10 mm in thromboelastometry eval-
uation. The mean dose of fibrinogen concentrates given was 1.6 g, and
haemostasis was achieved in all but 1 patient. The allogeneic blood prod-
ucts reduced significantly after FI administration: reduction of 81.4% of
RBC, 60.8% of FFP and 69.3% of PLT. Four patients died with conditions
related to surgery, 3 of them more than 24 h after surgery.
Conclusions: Administration of FI concentrates in patients undergo-
ing complex cardiac surgeries associated with coagulopathy and severe
bleeding significantly reduced the need for allogeneic blood products
support, though the dose of FI given was lower than the doses referred
in most studies. The use of thromboelastometry allows a rapid identifi-
cation and characterisation of coagulopathic patients and enable us to
manage bleeding with a prompt and targeted administration of haemo-
static products, with a favourable cost-benefit ratio.
P78
Influence of Factor XIII Levels on Clot Firmness during
Major Paediatric Surgery
T. Haas1 , N. Spielmann1 , M. Cushing2 , M. Schmugge3 & M. Weiss1
1 Department
of Anaesthesia, University Children’s Hospital Zurich,
Switzerland; 2 Department of Pathology and Laboratory Medicine, Weill
Cornell Medical College, New York, NY, USA; 3 Department
of Haematology, University Children’s Hospital Zurich, Switzerland
Introduction: Acquired hypofibrinogenemia is one of the main reasons
for the development of intraoperative coagulopathy. Functional fibrino-
gen activity can be rapidly measured by viscoelastic testing (ROTEM®)
using the FIBTEM assay to analyse firmness of the fibrin clot after 10
minutes (A10 test). Factor XIII (FXIII) has been shown to play a major
role in clot firmness. However, the influence of different FXIII levels on
the FIBTEM test following administration of fibrinogen concentrate has
not been analysed.
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 45
Methods: Data from a randomised, controlled, phase IV trial (Clini-
calTrials.gov Identifier: NCT01487837) was used for post hoc analysis.
After randomisation into two different trigger levels to initiate fibrino-
gen substitution (FIBTEM MCF <8 vs. <13 mm), all children in this trial
were treated with fibrinogen concentrate (dose 30 mg/kg) if predeter-
mined hypofibrinogenemia was detected. ROTEM® FIBTEM test and
FXIII levels were analysed before and within 15 minutes after admin-
istration of fibrinogen concentrate. Three groups of activity were deter-
mined (FXIII level <30% (A), 30–59% (B), and ≥60% (C)). Data were
statistically analysed by comparison of mean differences in FIBTEM A10
using the Mann-Whitney Test (p < 0.05 was determined to be statisti-
cally significant).
Results: The mean (IQR) increase in FIBTEM A10 following admin-
istration of fibrinogen concentrate was 1.5 mm (0–2.25 mm) in group
A (n = 18), 2.0 mm (1.0–3.0 mm), in group B (n = 28), and 3.0 mm
(2.0–3.0 mm) in group C (n = 21). Results of group C were significantly
higher compared to group A (p = 0.007), while no significant differences
were observed between groups A and B (p = 0.097), and groups B and C
(p = 0.174).
Conclusion: The results of this study demonstrate a significantly higher
in vivo recovery of FIBTEM clot firmness (A10) following administra-
tion of 30 mg/kg fibrinogen concentrate during major paediatric surgery
if concomitant FXIII levels were ≥60%, as compared to critically low lev-
els of FXIII (<30% level). The mean differences might have been even
more pronounced if larger doses of fibrinogen had been administered.
Thus, it seems prudent to assess and restore FXIII levels when hypofib-
rinogenemia needs to be treated. Further research is needed to confirm
these results and determine the exact threshold for FXIII replacement.
P79
Implementation of a Perioperative
Thromboelastometry-guided Transfusion Algorithm
for Cardiac Surgery Reduces Transfusion and Increases
Number of Patients without Any Transfusion
T. Frenzel1 , D. M. Rotteveel-de Groot2 ; E. C. van Pampus3 ; N. Horn4 ;
L. Noyez5 & J. G. van der Hoeven1
1 Department of Intensive Care Medicine, 2 Department of Laboratory
Medicine, 3 Laboratory of Medical Immunology, 4 Department
of Anaesthesiology, 5 Department Thoracic and Cardiac Surgery, Radboud
University Medical Centre, Nijmegen, The Netherlands
Introduction: Postoperative bleeding is common after cardiac surgery.
Perioperative bleeding, coagulopathy and allogeneic blood transfusion
are independently associated with increased morbidity and mortality
in these patients. (1) Algorithms have been shown to improve haemo-
static therapy compared to empiric therapy. (2) There is an increasing
number of studies pointing to superiority of a protocol incorporating
point-of-care (POC) testing like thromboelastometry and whole blood
impedance aggregometry for platelet function analysis. (3)
Methods: We have been using a lab-guided transfusion algorithm for
cardiac surgery in our hospital, which served as our control (2013). In
early 2014 we implemented a perioperative transfusion algorithm for
cardiac surgery using thromboelastometry and whole blood impedance
aggregometry and monitored prospectively effects on transfusion
requirements, postoperative bleeding, resternotomy and hospital
mortality.
Results: Patient characteristics were comparable in the two study periods
(Feb-June 2013 vs. Feb-June 2014) including number of patients (n = 333
vs. 328), type of surgery, sex, age (66.5 ± 10.2 vs. 66.5 ± 11.9 years), BMI
(27.3 ± 4.4 vs. 27.1 ± 4.3) and log EuroSCORE (5.4 ± 6.2 vs. 5.4 ± 6.7).
Transfusion of packed cells (148 vs. 108 units), fresh frozen plasma (52
vs. 8 units) and platelet concentrates (138 vs 72 units) decreased and
significantly more patients did not receive any blood products periop-
eratively (n = 133 vs. 193) after implementation of the new algorithm.
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
46 Abstracts of the 16th Annual NATA Symposium
Postoperative bleeding (drain volume at 1 and at 8 hours on ICU) was
not statistically different (median 170 and 440 mL vs. 180 and 400 mL).
Number of resternotomies was reduced from 27 to 15 and hospital mor-
tality stayed on the same level (0.9 vs. 1.2%).
Conclusions: Implementation of a thromboelastometry-guided trans-
fusion algorithm for cardiac surgery reduced transfusion and increased
number of patients without transfusion, whereas postoperative bleeding,
rate of resternotomy or hospital mortality were not affected.
REFERENCES
1. Murphy GJ et al. Circulation 2007;116:2544-52.
2. Avidan MS et al. Br J Anaesth 2004;92:178-86.
3. Görlinger K, Dirkmann D, Hanke AA. Curr Opin Anaesthesiol
2013;26:230-43.
P80
Massive Haemorrhage Management: From Chaos
to Order – Legnano Hospital’s Experience
I. Beverina1 , C. Novelli1 , A. Aloni1 , M. Lucchelli2 , E. Borotto2
& B. Brando1
1 Blood Transfusion Centre and 2 Intensive Care Unit, Legnano General
Hospital, Legnano (Milano), Italy
Introduction: Management of massive haemorrhage (MH), regardless
of its aetiology (trauma, obstetrical, surgical), needs an active collab-
oration among the involved clinical team and the Transfusion and
Haematology Laboratory services. MH is associated with high mortality
especially in trauma patients. Various guidelines recommend that each
institution implements a specific protocol for the management of this
life-threatening situation. Before November 2012 our behaviour in this
dramatic clinical occurrence was objectively chaotic and uncoordinated.
Haemocomponents and haemoderivatives were released and transfused
in a not standardised amount and were only slightly targeted to lab test
results.
Methods: In December 2012 we undertook a multidisciplinary and
multistep approach to MH. After a revision of the recent literature and
several meetings and discussions with all the involved professionals
(transfusionists, intensivists and emergency surgeons) we developed a
shared MH protocol, activated by the intensivist in case of class III/IV
shock unresponsive to a 2 L bolus crystalloid infusion. We started the
production of pooled cryoprecipitate, always subjected to quality control
for fibrinogen (FBG) content and our integrated haematology laboratory
was in charge of the management of all the diagnostic and therapeutic
steps. Whenever possible, haemotherapy was guided by viscoelastic test
(ROTEM®) results. For the first transfusion pack, we chose a fixed
Red Blood Cell (RBC)/Fresh Frozen Plasma (FFP) ratio of 1.3 (4RBC
units/3FFP units), with an extra platelet pool (PP) in the second pack.
After implementation, all the more critical cases were audited in plenary
meetings and any procedural flaw was evidenced and discussed. MH was
formalised by the Hospital’s Management in November 2013.
Results: From November 2013 to June 2014 we managed 18
post-traumatic MHs. All patients (pts) were transfused with RBC
(mean units 9; min 4 – max 17) and plasma (mean 1700 mL; min
795 – max 3165). 66% percent of pts underwent PP transfusions (mean
units 1.75. min 1 – max 4). The mean RBC/PFC ratio was 1.4. Two
thirds of pts had a fibrinogen concentration below the established target
(150 mg/mL) and were transfused with cryoprecipitate (mean FBG
administered/transfusion episode 3.2 gr). Seventeen pts out of eighteen
survived (94.5%). One paediatric patient died as a result of a severe head
trauma, after resolution of the acute haemorrhage. Retrospective data
analysis shown an inappropriate MH protocol activation in one case
(5.5%). As time went by, the transfusionist became a trusted consultant
rather than an automatic blood dispenser.
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
Conclusions: The implementation of a MH protocol helped us to pro-
vide a faster and more appropriate treatment to the patients. Based on
coagulation data at admission and during the acute clinical course, the
latest protocol version focused on hypofibrinogenemia with the inclu-
sion of cryoprecipitate (2 grams) in the first pack. Works are in progress.
P81
A Retrospective Audit of the Massive Transfusion Protocol
Activation in Tan Tock Seng Hospital (TTSH), Singapore
H. Toh, H. G. See & J. E. J. Tan
Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan
Tock Seng Hospital (TTSH), Singapore
Introduction: We performed the first retrospective audit of activations
of the massive transfusion protocol (MTP) from December 2011 to Jan-
uary 2013 in our 1500 bed tertiary hospital in Singapore. We reviewed
compliance to activation triggers, protocol guidelines, blood product
usage and ratios, use of tranexamic acid, maintenance of patient tem-
perature, acid-base, ionised calcium (iCa), haemoglobin (Hb) levels and
coagulation profile.
Methods: We reviewed hospital-based electronic records of the emer-
gency department admission notes, operation reports and anaesthetic
charts; the TTSH Trauma data registry and the TTSH Blood Transfusion
Service records of MTP activations
Results: 24 cases of MTP activation were identified and 23 cases were
analysed as the last had incomplete records. All cases met the criteria
for active bleeding and having an active surgical plan. Compliance to
activation after a requisite volume of fluids was administered was poorly
documented and 22% of cases did not comply. 17% of cases had their
MTP product ratio altered. Temperature was monitored in 72% of cases
but only 30% achieved at least 35 ∘ C at the end of surgery. Tranexemic
acid was administered in 80% of the cases in the OT. 95% of cases
monitored acid-base balance but only 41% achieved a pH of at least 7.2.
iCa levels above 0.9 mmol/L were only achieved in 56% of cases, with
the remaining 44% having lower end-surgery levels than at the start.
An Hb of at least 9 was achieved in 65% of cases post-intervention and
coagulation targets were met in more than 50% of the cases. Packed
cells (PCT) to plasma to platelets were given at a ratio of 1.6:1:1.3; and
crystalloid to PCT at a ratio of 1:1.18. 47% of cases survived to hospital
discharge.
Conclusion: MTPs when triggered appropriately achieve the desired
rapidness of blood product delivery and product ratios transfused.
Greater efforts to address other physiological targets and non-blood
product therapy should be focused on to achieve better clinical out-
comes. Documentation in crisis for quality improvement remains a chal-
lenge that needs focus and a systems solution. Better means of evaluating
real time patient response to MTPs need to be developed and included
in our next haemostatic resuscitation protocol.
P82
Use of Recombinant Activate Human Factor VII
in a University Hospital (2008–2013)
E. Chica1 , C. Escolano1 , H. Pérez Domínguez2 , P. Peralta2 , E. Duro2 ,
C. García Molina2 & F. Oña1
1 Department of Hematology, 2 Department of Anaesthesiology, Hospital
Universitario de Getafe, Madrid, Spain
Introduction: Recombinant coagulation factor VII (rFVIIa) was devel-
oped initially for the treatment by patients who suffered haemophilia A
or B with inhibitors, Glanzmann thrombasthenia and those with coagu-
lation factor VII deficiency; but due to its haemostatic capacity is mainly
used “off-license”. In the last European guidelines, its compassionate use
in case of massive bleeding is a “2C” recommendation, given the lack of
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

evidence to support their use and the proven high risk of thromboem-
bolic complications in addition to the elevated cost.
Objectives: To perform a retrospective review about the use of recom-
binant activated human factor VII in our hospital between years
2008–2013 to check its indications, effectiveness and verify if the use of
this drug has decreased according to current recommendations.
Material and Methods: Available data about rFVIIa administration was
requested to our hospital pharmacy and each clinical case was analysed
individually. The following variables were recorded: sex, age, comorbid
factors, indication, dose, transfusion necessity, outcomes and incidence
of thromboembolic complications.
Results: In this period of time, rFVIIa was used in 110 patients (23
in 2008, 21 in 2009, 32 in 2010, 12 in 2011, 10 in 2012 and only 5 in
2013), 71 male (64%) and 39 female, with mean age of 54 years. In 24
cases (22%) was a preoperative prophylaxis in patients with deficit of
coagulation factor. Of the remaining 86 cases (78%): 41 (37.3%) was for
massive transfusion, 33 (30%) for incoercible bleeding (7 associated with
anticoagulation, 13 produced by coagulopathy in cirrhosis and 13 caused
by intercurrent process), 10 patients (9%) for neurosurgical bleeding and
in 2 cases the indication was not clear. Alive are 53% and 47% died (22%
in the first 24 hours). The dose in these cases was 90 μg/Kg. Only 3 cases
(3.5%), thrombotic complications were found, and not clearly caused
by drug.
Conclusions: The use of rFVIIa has decreased substantially in the last
year coherently with the actual recommendations and besides its utilisa-
tion in anticoagulated patients has been replaced by the introduction of
prothrombin complex concentrate. His most frequent indication in our
centre was “off label”. Both early and late mortality was elevated, as befits
the compassionate use; it was in most cases, in serious situations without
clear alternatives. The number of thrombotic complications is low in our
series.
REFERENCES
1. Bardon J, Fink J, de Montblanc J, Bergmann JF, Sarrut B, Benhamou
D. [Off-label use of recombinant factor VII (rFVIIa) in teaching hospitals
in Paris in 2010]. Ann Fr Anesth Reanim 2013;32:659-64.
2. Welsby IJ, Monroe DM, Lawson JH, Hoffmann M. Recombinant
activated factor VII and the anaesthetist. Anaesthesia 2005;60:1203-12.
3. Kozek-Langenecker SA, Afshari A, Albaladejo P, et al. Management
of severe perioperative bleeding: Guidelines from the European Society
of Anaesthesiology. Eur J Anaesthesiol 2013;30:270-382.
P83
Impaired Coagulation Control Mechanisms in Trauma
Patients with Disseminated Intravascular Coagulation
at an Early Phase of Trauma
S. Gando, A. Sawamura, M. Hayakawa, T. Wada, J. Yanagida,
D. Miyamoto, K. Maekawa, Y. Ono, K. Katabami & A. Mizugaki
Division of Acute and Critical Care Medicine, Department
of Anaesthesiology and Critical Care Medicine, Hokkaido University
Graduate School of Medicine, Sapporo, Japan
Introduction: We tested the hypothesis that impairment of coagulation
control mechanisms and increase in systemic thrombin activation occurs
both in disseminated intravascular coagulation (DIC) with the fibri-
nolytic phenotype and acute coagulopathy of trauma shock (ACOTS)
at an early phase of trauma.
Methods: Fifty-seven trauma patients, including 30 patients with DIC
diagnosed based on Japanese Association for Acute Medicine scoring
system and 27 patients without DIC were prospectively studied. Patients
with ACOTS, defined as a prothrombin time ratio >1.2, were also
investigated. Twelve healthy volunteers served as control subjects. The
levels of soluble fibrin, antithrombin, and soluble thrombomodulin were
measured on days 1 and 3 following trauma. Systemic inflammatory
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 47
response syndrome (SIRS) and the Sequential Organ Failure Assessment
(SOFA) were scored to evaluate the extent of inflammation and organ
dysfunction.
Results: DIC patients showed more systemic inflammation and higher
SOFA scores, and were transfused with more blood products than
the non-DIC patients. On day 1, increased soluble fibrin, lower lev-
els of antithrombin, and higher levels of soluble thrombomodulin were
observed in DIC patients in comparison with control subjects and
non-DIC patients. These changes were more prominent in DIC patients
who met the International Society on Thrombosis and Haemostasis overt
DIC criteria. The multiple regression analysis showed that antithrom-
bin is an independent predictor of high soluble fibrin in DIC patients.
Higher levels of fibrin and fibrinogen degradation products, D-dimer
and the fibrin and fibrinogen degradation products/D-dimer ratio indi-
cated increased fibrin(ogen)olysis in DIC patients. Almost all ACOTS
patients overlapped with the DIC patients. Therefore, the changes in
the measured variables in ACOTS patients coincided with those in DIC
patients.
Conclusion: Insufficient coagulation control give rise to systemic
increase in thrombin generation and its activation in patients with DIC
with fibrinolytic phenotype at an early phase of trauma. The same is true
in patients with ACOTS, and shutoff of thrombin generation was not
observed.
P84
Effects of Implementation of Damage Control Resuscitation
Practices: From Massive Transfusion Protocol (MTP)
to Thromboelastometry (ROTEM®)-based Transfusion
Algorithm
M. Barquero López
Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
Introduction: Massive haemorrhage in trauma is associated with coag-
ulopathy and high mortality. In the last years we have seen multiple
changes related to coagulopathy and consequently its treatment: from the
introduction of the empirical MTP to an increased interest in thromboe-
lastometry and thromboelastography to monitor trauma patients. In our
hospital, a trauma reference centre, we have reflected all these changes in
our transfusion algorithm. We have analysed the change in the pattern of
treatments and its correlation with analytical parameters of coagulation
and hypoperfusion.
Methods: Retrospective analysis of trauma patients with severe
haemorrhage from 2008 to Jan 2014. Trauma patients were grouped
into 3 time periods: pre-MTP (before 2009) / MTP (2009-2011) /
MTP + ROTEM®-based transfusion algorithm (2012-Jan 2014).
We have analysed clinical and demographic characteristics, blood
products transfusion, fibrinogen concentrate administration, laboratory
results (haemoglobin, platelets, PT ratio, aPTT ratio, fibrinogen value
and lactic acid value) and ROTEM® parameters upon arrival and after
24 h.
Results: The strategy based on the MTP is related to an increase of
platelet concentrates consumption and a decrease in the use of fresh
frozen plasma (FFP). We have observed a decrease in the number of
coagulopathic patients (PT >1.2 ratio) and patients with high lactic acid
value (>22 mg/dL) after 24 hours from arrival. However these findings
are not statistically significant.
After getting a goal-directed transfusion therapy based on thromboe-
lastometry the empirical treatments have decreased, all coagulopathic
patients have received fibrinogen concentrates (3.5 g/patient), aiming a
negative correlation between PT ratio and fibrinogen value after 24 h
from arrival (p < 0.0001), the use of FFP has decreased (p < 0.0001). The
number of coagulopathic patients (p < 0.0001) and patients with high
lactic acid value have decreased. Finally, we have aimed a negative cor-
relation between fibrinogen value and lactic acid value after 24 h from
arrival (p = 0.002).
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
48 Abstracts of the 16th Annual NATA Symposium
Conclusion: The implementation of MTP allows an aggressive and
immediate treatment of coagulopathy but it is empirical, noting a declin-
ing trend of coagulopathic patients, non-statistically significant. Adding
thromboelastometry to the MTP allows an immediate and aggressive
treatment of coagulopathy with a decrease of the empirical treatments
and blood products transfusion, especially for FFP, and a best analytic
parameters after 24 hours. So, we recommend the combined approach
consisting of MTP + ROTEM®-guided algorithm early in the treatment
of trauma patients with severe haemorrhage.
P85
Transfusion Requirements: Analysis before and after
the Introduction of Trombelastometry Guided Factor
Concentrate Based Algorithm for the Therapy
of Coagulopathy in Massive Bleeding
I. Zýková, P. Sedlák & D. Morman
Anaesthesia and Intensive Care Department, Regional Hospital Liberec,
Liberec, Czech Republic
Introduction: Our intensive care unit is a general mixed ICU with 9
beds in a regional trauma centre. We admit over 300 patients/year. We
started using trombelastometry (ROTEM) in 2009. In January 2014 we
implemented POC (trombelastometry guided) factor concentrate based
coagulation algorithm for the early and individualised goal-directed
therapy of massive bleeding. Our practice for the treatment of bleeding
and our utilisation of blood products has changed dramatically.
Methods: Retrospective analysis of the utilisation of blood products
(PRBC, FFP and platelet concentrates) evolving in time before and after
the introduction of POC (thrombelastometry) guided factor concentrate
based coagulation algorithm in our intensive care unit.
Results: The use of all allogeneic blood products (PRBC, FFP, platelet
concentrates) has decreased by approximately by 50% in our unit after
the introduction of the algorithm. Administration of PRBC was reduced
by approximately 20%, administration of platelet concentrates by 35%,
and administration of FFP by approximately 85%.
Conclusion: We have achieved a major reduction in transfusion of
allogeneic blood products after the introduction of a POC guided fac-
tor concentrate based treatment algorithm in our intensive care unit.
Our data support the data already published1 . Implementation of algo-
rithm reduces the exposure of intensive care patients to allogeneic blood
products.
REFERENCE
1. Schöchl H, Maegele M, Solomon C, Görlinger K, Voelckel W. Early
and individualized goal-directed therapy for trauma-induced coagu-
lopathy. Scand J Trauma Resusc Emerg Med 2012;20:15.
P85 Figure
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
P86
Thrombelastography and Functional Fibrinogen Reference
Ranges in Healthy Full Term Pregnant Women
L. Eastwood, R. Mitha, K. Pendry, J. Thachil & P. Kochhar
Central Manchester University Hospitals NHS Foundation Trust,
Manchester, UK
Introduction: Recent reviews of massive haemorrhage protocols within
UK hospitals and renewed interest in global haemostasis tests have sug-
gested that the introduction of thrombelastography (TEG) and func-
tional fibrinogen tests for use in post-partum haemorrhages (PPH) may
prove beneficial. TEG is a near patient test that assesses viscoelastic
properties of blood samples under low shear conditions. Functional fib-
rinogen is a modification of this test which allows measurement of the
fibrinogen level. No statistically valid published reference ranges for this
category of patients meant that there was a need for these reference
ranges to be produced. This would allow for an algorithm to guide blood
product usage based on TEG and functional fibrinogen results to be con-
structed.
Method: TEG, functional fibrinogen, full blood count, prothrombin
times, activated partial thromboplastin times and Clauss fibrinogen
assays were performed on blood samples collected from 120 full term
pregnant women at St Mary’s Hospital, Manchester, UK. Informed con-
sent was obtained from all participants and the study was ethically
approved by the National Research Ethics Service (NRES) Committee
North West – Haydock.
Results: TEG and functional fibrinogen reference ranges for healthy
full term pregnant women were established demonstrating a hyperco-
agulable state. R time: 1.2-5.5 min, K time: 0.6-1.4 min, alpha angle:
69.5-81.7o , maximum amplitude: 71.4-83.2 mm, lysis 30: 0.0-3.6% and
functional fibrinogen: 15.8-44.6 mm.
Conclusion: The reference ranges produced as part of this study demon-
strate that there is a significant difference between the results of full term
pregnant women and the general population. Increasing awareness of the
TEG and functional fibrinogen tests may help them to achieve their full
potential in the obstetric setting.
P87
Blood Loss Auto-Monitoring and Estimation in Early
Puerperium Using a Pictorial Method
S. Xodo, G. Straface & V. Zanardo
Policlinico Abano Terme, Abano Terme, Italy
Introduction: There are still some open issues about postpartum haem-
orrhage (PPH). First a univocal definition for PPH does not exist in the
literature. Second, visual estimation of blood loss is notoriously inaccu-
rate. Furthermore there is poor agreement between visual estimation by
healthcare professionals and actual blood loss determined by laboratory
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

methods. The aim of our study was to verify both the reliability of the
method and the method’s accuracy by involving women in the process
of blood loss monitoring.
Methods: We conducted a prospective cohort study, from February 1
to March 15 2013, at the Division of Perinatal Medicine of Policlinico
Abano Terme, in Abano Terme (Italy). According to the study protocol
we used a graduate post-partum bag to collect the blood loss at delivery.
To estimate the subsequent bleeding puerperes were trained to register
their blood loss in an appropriate pocket card; health professionals had
to check the results every 2 hours. We adopted the pictorial method
proposed by Bose, quantifying the blood on pads, swabs and sanitary
towels. After 24 hours patients underwent a blood test so that the
estimated blood losses were compared with the blood values. Statistical
analysis was performed using IBM SPSS Windows statistical package
(version 13).
Results: We conducted the analysis dividing our population in 2 groups,
according to the different BMI, i.e. normal weight women (with a BMI
<25) and overweight/obese women (with BMI >25). The guiding prin-
ciple was that overweight and obese women have a higher risk of PPH.
We then compared the two groups as for anthropometric characteristics
and pregnancy and post-partum outcomes. Mean total blood loss at 24
hours post-partum was higher in overweight/obese women than in nor-
mal weight women, but there was no statistically significant difference
between the 2 groups. The haemoglobin difference pre- and 24 hours
post-partum was higher in the group of overweight and obese women,
there was a statistically significant difference between the two groups
(p = 0.007). We then classified each group into 3 categories according to
the obstetric blood loss: <500 mL, 500–1000 mL and >1000 mL. Women
having a worse BMI had a higher tendency to undergo a PPH. In the
third category, characterised by the major blood loss (>1000 mL), over-
weight women are found more frequently than normal weight women
(8/24, 33.33% of overweight/obese women versus 11/88, 12.5% of nor-
mal weight women, RR 2.66; CI: 1.20–5.88). This difference was statisti-
cally significant (p = 0.028).
Conclusion: We demonstrate in this study that Bose’s visual aid is
an accurate and efficient method to estimate and auto-estimate the
vaginal blood losses in the post-partum period. High risk women, who
underwent a greater decrease in the haemoglobin level, had also a greater
bleeding, which was correctly identified using this method. A complete
novelty of our experience is that we involved puerperes so that they
could auto-monitor the post-partum bleeding. We think that such visual
aid can not only support the assessment of healthcare professionals in
the obstetric blood loss estimation, but also ensure that the bleeding
monitoring continues at home, after discharge.
P88
When the Bleeding Does Not Stop – How Do We Transfuse
Obstetric Patients?
J. Fonseca, S. Mota, I. Cunha, C. Alves & J. Carvalhas
University Hospital of Coimbra, Maternidade Dr. Daniel de Matos,
Coimbra, Portugal
Introduction: Massive transfusion of blood products is required as a
life-saving practice in a minority of peripartum haemorrhages. Our goal
is to characterise the transfusion practice on those women who were
massively transfused over a 2 year period (October 2012 to October
2014) in a reference obstetric unit. The obstetric unit is 15 minutes away
from the blood bank and laboratory; there are no uncrossmatched blood
units, prothrombin complex concentrate (PCC) or thromboelastometry
(ROTEM) available on the premises. Both fibrinogen and tranexamic
acid (TNX) are available.
Methods: We conducted an observational retrospective study on mas-
sive transfusion in the obstetric setting. A listing of patients trans-
fused over this period was requested from the blood bank; those given
4 or more packed red blood cells (PRBC) in less than 4 hours were
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 49
considered. Charts and files were sourced for data on demographics,
obstetrics, co-morbidities, haemoglobin (Hb) levels, blood products
transfused. Data were analysed using descriptive methods and associa-
tions were ascertained using the Pearson correlation. A p value less than
0.05 was considered significant.
Results: 5018 births took place. 2.9% (n = 144) of women were trans-
fused. 10.4% (n = 15) met the criteria for massive transfusion. Mean age
was 36 (±6) years old and gestational time 37 (±3) weeks. 33% (n = 5)
had anaemia (Hb <11.5 g/dL) prior to the event. No history of coagu-
lopathy in any of the patients. Pre-eclampsia (n = 3) and HELLP (n = 2)
were found. The mean Hb that triggered transfusion was 6.5 (±1.5)
g/dL, and post-transfusion was 10.4 (±1.5) g/dL. A reverse association
between these two variables was found (Pearson -0.72). An average of 7
(±2) units of PRBC were administered per patient; the number of PRBC
transfused correlates with age (Pearson 0.64) and risk for hysterectomy
(Pearson 0.62). 13 women received fresh frozen plasma (FFP) (mean 5
U), 11 fibrinogen (mean 2.6 g), 6 platelets (mean 1.5 pools), 4 tranexamic
acid (1 g each) and 2 PCC (500 U each). All women survived and there
were no cases of TRALI or TRIM.
Conclusion: Despite the small sample size, it is clear that the transfusion
practice varied from case to case. There is also a tendency to overtrans-
fuse the most severe patients. The distance from the blood bank can shed
an explanation for this defensive practice. To standardise massive trans-
fusion management, institutional protocols tailored to the obstetric field
should be discussed and implemented. Moreover, efforts are being made
to acquire a ROTEM for our obstetric unit.
REFERENCE
Abdul-Kadir R, McLintock C, Ducloy AS, et al. Evaluation and man-
agement of postpartum hemorrhage: consensus from an international
expert panel. Transfusion 2014;54:1756-68.
P89
Massive Obstetric Bleeding – Effective Multidisciplinary
Approach
S. Mota, J. Fonseca, R. Cabral, S. Marques, C. Alves, M. Gil Pereira & J.
Carvalhas
Department of Anaesthesiology, Centro Hospitalar e Universitário de
Coimbra, Coimbra, Portugal
Introduction: Massive obstetric bleeding is defined as blood loss supe-
rior to 2 L and is the main cause for maternal death (1) (2).
Case Report: A 30-year-old G1P0 at 36 weeks gestation, asthmatic and
diabetic (type I). She was admitted due to foetal miscarriage. Labour was
complicated due to shoulder dystocia of a macrosomic foetus. Refrac-
tory atonic uterus was diagnosed immediately after delivery with subse-
quent post-partum massive haemorrhage. Anaesthesia consultation was
promptly obtained. Two wide bore intravenous cannulas were placed and
volume replacement started with 2.5 L of crystalloids. The Blood Bank
and the Immunohematology were contacted and an emergent transfu-
sion of 2 units of unmatched packed red blood cells (RBC) started. Emer-
gent hysterectomy was considered and the patient was transferred to the
operating room (OR). At this time total blood loss was 5 L. Fluid resus-
citation, coagulopathy and hydro-electrolyte disturbances were man-
aged according to laboratory values and serial arterial blood gas analysis
while, at the same time, local haemostatic manoeuvres were attempted
to avoid a hysterectomy. This required continuous, effective and clear
communication between the various health professionals (in the OR and
between the OR and the blood bank). In total, 10 units of RBC, 12 units
of fresh frozen plasma, 1 pool of platelets, 4 g of fibrinogen and 1000 U
of prothrombin complex concentrate were administered. A uterine com-
pression suture (B-Lynch suture) was performed successfully. Surgical
procedure lasted for 3 h20 min. The woman was then transferred to the
intensive post-anaesthetic care unit, where she remained uneventful for
45 h.
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
50 Abstracts of the 16th Annual NATA Symposium
Conclusion: Atonic uterus is the most common cause for massive bleed-
ing in obstetrics.1,2 A multidisciplinary approach with effective com-
munication and teamwork are essentials. In this case, the anaesthetist
played a key role in keeping vital stats optimised, so that a conserva-
tive approach could be possible. This required effective communication
with Immunohematology service and the obstetrician. Despite the sever-
ity of the situation and the clotting factors consumption coagulopathy,
swift blood products administration, careful hydro-electrolyte balance
and cardiac output maintenance were crucial to be able to safely avoid a
hysterectomy, preserving fertility.
REFERENCES
1. ISRN Obstet and Gynecol 2012:854064
2. Anaesth Intensive Care 2008:9:1
P90
Treatment of Disseminated Intravascular Coagulation
Caused by Amniotic Fluid Embolism
J. Mannova & P. Longin
Department of Anaesthesia and Resuscitation, Hospital Havlickuv Brod,
Havlickuv Brod, Czech Republic
Introduction: Amniotic fluid embolism (AFE) is associated with higher
mortality rates (50-80%) and due to this it is one of the most feared
complications in pregnancy. It is believed that amniotic fluid and foetal
cells enter the maternal circulation and trigger a prophylactic reaction to
foetal antigens. The first signs of AFE are pulmonary and cardiac. Most
women die of heart failure and even if they survive the initial period, after
a latent period of 0.5–4 hours, disseminated intravascular coagulation
(DIC) may occur and the patients mostly die of uncontrolled excessive
bleeding.
Case Report: A 32-year-old multipara was admitted to hospital expect-
ing to have a third baby. Twenty minutes after delivery she developed
breathing problems and hypotension. The treatment of both dyspnoea
and hypotension was initiated immediately by called anaesthesiologist.
Ultrasonography and revision of uteri provided by gynaecologist was
with no signs of bleeding. Thanks to the initial treatment, the woman
became haemodynamically more stable, with good oxygenation. How-
ever, within the next 30 minutes, excessive bleeding and signs of haem-
orrhagic shock were observed in the patient. In view of all the clinical
signs, a diagnosis of DIC caused by amniotic fluid embolism was deter-
mined and the treatment of DIC was started with tranexamic acid 1 g and
fibrinogen 4 g, both administered in the first minutes. Blood transfusions
of erythrocytes (8 x EBR) and plasma (8 x FFP) were given simultane-
ously with catecholamines in high doses, initially with no improvement
in haemodynamics. Knowing that it was a third pregnancy the gynae-
cologist decided for hysterectomy. All the measures led to the bleeding
being stopped during one hour, the patient became haemodynamically
stable with no catecholamines and no signs of continuing bleeding. The
parameters of coagulation were normalised and the patient was extu-
bated quickly. Previous laboratory examination confirmed the diagnosis
of DIC. No thrombotic complications were diagnosed and the woman
was discharged from hospital within 6 days.
Discussion: DIC in obstetrics is more of the bleeding type with predom-
inance of hyperfibrinolysis than of the thrombotic-hypercoagulation
type. Massive bleeding or the consumptive type can occur as well. In
the treatment of haemorrhagic DIC, EBR and FFP substitution is pre-
ferred, fibrinogen is recommended, while tranexamic acid is used only
rarely. Tranexamic acid significantly reduces the mortality of patients
with trauma and is administered in the case of traumatic bleeding
even without any signs of on-going hyperfibrinolysis. The evidence for
antifibrinolytics in obstetrics is limited. In our case we preferred early
administration of TA with fibrinogen in the first minutes of the manifes-
tation of haemorrhagic signs of DIC. This timely administration of TA
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
may have contributed to quickly restoration of coagulation parameters
and stopping bleeding.
Conclusion: Initial treatment with tranexamic acid in the case of DIC
caused by AFE should be considered. Its administration together with
fibrinogen in combination with other measures can lead to a successful
treatment of DIC caused by amniotic fluid embolism.
P91
Is Prothrombin Complex Concentrate Used Adequately?
Is Coagulopathy Correction Achieved? Our Experience
R. Castellanos-González, H. Pérez-Domínguez, D. Calles-Gato,
E. Chica, L. De la Cruz-Alvarado & C. García-Molina
Departments of Anaesthesiology and Haematology, Hospital
Universitario de Getafe, Madrid, Spain
Introduction: The number of patients treated with vitamin k antagonist
(VKAs) for prevention and treatment of arterial and venous thrombo-
sis, is continuously increasing. Traditionally, vitamin K and fresh frozen
plasma have been used to reverse the anticoagulant effects of this treat-
ment in cases of acute bleeding and urgent surgery. The problem is that
treatment with vitamin K does not have a quick effect; restoration of
haemostasis with fresh frozen plasma is quicker, but large volumes are
required to normalise the international normalised ratio (INR) and it is
not exempt from risks. Prothrombin complex concentrate (PCC) pro-
vides an alternative for rapid reversal of coagulopathy in VKA-treated
patients in case of emergency. Our aim is to study whether PCC is used in
our hospital with an adequate indication according to the current guide-
lines and its efficacy in normalising coagulation tests.
Methods: Available data about the PCC administration was requested
to our hospital pharmacy and we analysed each clinical case. We revised
articles about treatment with PCC published in Pubmed database. We
recorded variables as age, dose of PCC, prothrombin activity, INR and
aPTT before and after of PCC treatment and if the patients were treated
with vitamin K antagonist and why. We analysed the data using a
descriptive analysis.
Results: PCC was used in 39 patients with mean age of 74 years old. The
most of them (94%) received treatment with VKAs and the main rea-
son was atrial fibrillation (72%), followed by venous thrombosis or pul-
monary thromboembolism (10.8%). Among the most frequent causes
of treatment with PCC are neurosurgical bleeding (41%), uncontrol-
lable bleeding that threatens the patient́s life (30%) and anticoagulated
patients who need urgent surgery (10.25%). In a group of patients (17%)
the indication is questionable: multiorgan failure with coagulopathy or
small spontaneous bleeding. Mean baseline international normalised
ratio reduction was 1.25 after treatment with PCC; prothrombin activity
increased in 29.54% and aPTT decreased in 10.92 seconds (p < 0.001).
INR ≤1.2 was achieved in 44% of cases; INR 1.2 – 1.5 in 41.6% of
cases and INR > 1.5 in 13% of cases; that is, an acceptable coagulation is
achieved in more than 80% of patients and absolutely normal in almost
50%. Finally we found that the higher doses of PCC the major correction
of coagulation parameters.
Conclusions: PCC has not been used in all cases with a correct indi-
cation in our hospital. In most of the patients coagulopathy parameters
correction were achieved.
P92
Experience in the Use of Prothrombin Complex
Concentrate for Reversal of Apixaban Induced Bleeding
M. Estébanez1 , A. M. Borobia1,2 , J. A. García-Erce3 , A. M.
Martínez-Virto1 & M. Quintana-Díaz1
1 Emergency Department, La Paz University Hospital of Madrid, IdiPAZ;
2 Clinical Pharmacology Department, La Paz University Hospital
of Madrid, IdiPAZ, Spain; 3 Haematology Department, San Jorge Hospital
of Huesca, IdiPAZ, Spain
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

Introduction: The reversal of the effects of new oral anticoagulants
(NOAs) in patients with major bleeding is a challenge for clinical man-
agement in the emergency department (ED). There are scarce studies in
humans that have analysed the effect of PCC to antagonise the effect anti-
coagulant of NOAs. To date no data about apixaban reversal in humans
are available. We describe our experience in the ED with the urgent rever-
sal of apixaban anticoagulant using PCC.
Methods: We collected data from all patients administered apixaban
who were treated at the ED between October 2013 and September
2014. From these patients, we selected any patient who developed a
haemorrhagic complication reversal by PCC. We reviewed the clinical
data and coagulation parameters from electronic medical histories of
selected patients and we followed patients for three months to evaluate
the risk of thrombotic complications.
Results: 31 patients treated with apixaban were attended in ED in
the study period. Three patients developed a bleeding complication
reversal by PCC (Table). The median dose of 15 U/kg was effective
in controlling the extension of the hematoma and active haemorrhage.
The PCC infusion had no effect on the correction of homeostasis test
alterations induced by apixaban.
Conclusion: The use of PCC infusion could reverse apixaban-induced
bleeding in the emergency setting.
P93
High Versus Low Protamine-to-heparin Dosing Ratio
Following Cardiopulmonary Bypass: A Multicentre
Randomised Controlled Trial
M. I. Meesters, D. Veerhoek, L. J. M. van Barneveld, F. de Lange, J. W. de
Vries, J. W. A. Romijn, A. B. A. Vonk & C. Boer
Departments of Anesthesiology and Cardio-Thoracic Surgery, VU
University Medical Centre, Amsterdam, The Netherlands; Department
of Anaesthesiology Medical Centre Leeuwarden, Leeuwarden, The
Netherlands
Introduction: Guidelines for perioperative blood management advise
to dose protamine in a 1.0-1.3:1.0 ratio with heparin. However, due
to the degrading and loss of heparin during surgery, protamine can
be overdosed. Present study investigated whether the use of a lower
protamine-to-heparin dosing ratio is superior to a high dosing ratio with
respect to postoperative haemostasis.
Methods: In this multicentre investigation, patients undergoing coro-
nary artery bypass graft surgery were randomised into a low (0.8; n = 46)
or high protamine-to-heparin (1.3; n = 36) dosing group based on total
heparin administration. Patient haemostasis was monitored using rota-
tional thromboelastometry before and 3 and 30 minutes after CPB.
Results: CPB time estimated 89 ± 29 vs. 90 ± 36 minutes (p = 0.92)
in the low and high dosing groups. There were no differences in total
heparin dosing (412 ± 121 vs. 420 ± 92 mg; p = 0.75), while protamine
administration was lower in the 0.8 (331 ± 97 mg) than in the 1.3 group
(545 ± 120; p < 0.001). ACT values following protamine administration
were similar between groups. Clotting times for the INTEM (293 ± 64 vs.
P92 Table Demographic and clinical characteristics, bleeding complications
HAS-
Age, BLED Antiplatelet CrCl
years Gender Score treatment (ml/min)
91 Female 2 No 28 Post-traumatic chest wall haematoma
65 Female 2 No 66 Spontaneous knee haemarthrosis
77 Male 3 Yes 61 Upper gastrointestinal bleeding
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 51
243 ± 37 s; p < 0.001) and HEPTEM (298 ± 60 vs. 243 ± 40 s; p < 0.001)
were prolonged at 3 minutes following protamine administration in
the high dosing group, but were normalised 30 minutes later. Median
24-hour blood loss was increased in the high protamine dosing
group.
Conclusion: A protamine-to-heparin dosing ratio of 1.3 is associ-
ated with a temporary prolongation of postoperative clotting times
and increased blood loss when compared to a lower dosing strategy.
Protamine overdosing should therefore be considered harmful for the
restoration of perioperative haemostasis.
P94
Plasma Concentration of Tissue Factor (TF) and Tissue
Factor Pathway Inhibitor (TFPI) in Patients with Morbid
Obesity
A. Firszt-Adamczyk1 , P. Adamczyk2 , R. Szafkowski2 , M. Firszt3 , I.
Ponikowska2 , I. Iwan-Ziȩtek4 , B. Góralczyk1 , B. Ruszkowska-Ciastek1
& D. Rość1
1 Department of Pathophysiology Collegium Medicum, Bydgoszcz,
Poland; 2 Clinic of Balneology and Physical Medicine, Nicolaus
Copernicus University, Toruń, Collegium Medicum in Bydgoszcz, Poland;
3 Faculty of Mathematics and Computer Science, Nicolaus Copernicus
University, Toruń, Poland; 4 Department of Dermatology and Venerology,
Pomeranian Medical University, Szczecin, Poland
Introduction: Obesity, as a public issue, is rising in prevalence world-
wide. Morbid obesity, defined by the value of BMI >40 kg/m2 . The most
common cause of death among people with morbid obesity are cardio-
vascular complications as a result of hypercoagulability state. The aim
of the study was to evaluate the activation of the coagulation process
depending on the tissue factor and tissue factor pathway inhibitor.
Methods: Sixty patients were included to the study. Thirty-six patients
with morbid obesity, (F/M 28/8); the mean age of 46 years, as a study
group. The control group consisted of 24 healthy volunteers (F/M 16/8;
the mean aged of 39 years) with BMI ≤24.9 kg/m2 . All patients were
under the care of the Clinic of Balneology and Physical Medicine of the
Medical University in Ciechocinek, Poland. Plasma concentrations of TF,
TFPI, TAT complexes were performed by Enzyme Linked Immunosor-
bent Assay (ELISA), however the concentration of fibrinogen was mea-
sured in an automated coagulometer CC-3003 apparatus and reagents
were purchased from Bio-Ksel Co., Poland.
Results: There were observed significantly higher concentrations of
tissue factor, thrombin-antithrombin complexes and fibrinogen in obese
patients relative to controls, as well as a significant higher concentration
of TFPI.
Conclusions: Morbidly obese patients are in constant hypercoagulability
state (increase in the concentration of TF, TAT complexes and fibrino-
gen), despite of lack of clinical evidence. Essential inhibitory potential of
the extrinsic pathway was found in those patients, based on the increased
concentration of TFPI.
Time from
admission
Bleeding PCC dose RBC (No. to bleeding
complications (IU) [IU/kg] of units) cessation
1000 [18] No <12 h
1000 [15] No <6 h
1000 [11] Yes (6) <6 h
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
52 Abstracts of the 16th Annual NATA Symposium
P95
Thromboembolic Events and Thromboprophylaxis in Major
Spinal Deformity Surgery
L. Mora1 , M. J. Colomina1 , A. Vila-Casademunt2 , E. Ciércoles1 , E.
Guerrero1 , J. Bagó3 , F. Pellisé3 & European Spine Study Group
1 Vall d́Hebron University Hospital, Department of Anaesthesiology,
Barcelona, Spain; 2 Vall d́Hebron University Hospital, Research
and Development Department, Barcelona, Spain, 3 Vall d́Hebron
University Hospital, Department of Surgery, Barcelona, Spain
Introduction: Major spinal surgery in adults is associated with signifi-
cant perioperative blood loss and up to a moderate risk of venous throm-
boembolism (VTE) (0.1% to 12%), with differences by anatomic region
and type of surgery. There is no consensus about the use of pharmacolog-
ical agents for non-traumatic procedures because of the risk of epidural
haematoma. In regard to the safety of this highly complex surgery, its
assessment deserves to be considered.
Aims: The aim of the study was to verify the incidence of VTE in
our spinal deformity surgical adult patients. A secondary goal was to
undertake a global thromboprophylaxis protocol in spinal surgery in
order to prevent severe complications and improve the quality of care
provided.
Methods: A single-centre, retrospective review of prospectively collected
data was performed. Patients older than 18 years with any coronal or
sagittal deformity were included; spinal cord injuries and cancer patients
as well as cervical surgeries were excluded. Preoperative condition, blood
tests, bleeding and transfusion registers and postoperative complications
were recorded. We reported a thromboprophylaxis recommendations
protocol for the postoperative period.
Results: A total of 75 patients, 57 women and 18 men with a mean age of
50.1 years (SD19.5), who underwent 88 major reconstructive deformity
surgeries, met the inclusion criteria. Mean surgical time was 405.5 min
(SD 141.8) with an average total (plus 24 h drainage volume) blood loss
of 2485 mL (SD 1345.2). The transfusion rate was 68.2%, with a mean of
2.1 units (0-11). Fibrinogen was administered in 14.8% of surgical cases
(mean dose 2.23 g) and only one patient required 600 IU PCC. Tranex-
amic acid (TXA) was used intra-operatively in 36.7% of procedures.
Coagulation variables were within normal perioperative limits. Intraop-
erative high blood loss was related to more postoperative general com-
plications (P = 0.0081). Mechanical thromboprophylaxis (97.7% pneu-
matic compression) was performed in 100% of patients and additional
enoxaparin was administered in 12.5%, according to our criteria under
the comorbidities and interventions’ characteristics. Our incidence of
global VTE events was 4.54%. Two cases of postoperative pulmonary
embolism (2.3%), diagnosed by CT, one of which had been treated with
TXA and two cases of venous thrombophlebitis (2.3%), diagnosed by
Doppler (one with TXA), occurred. The mortality of all procedures and
complications was 0%.
Conclusion: Because of the clinical implications of serious thromboem-
bolic events it is worth making an effort to set out a prevention protocol
that favours the use of pharmacological prophylaxis in high-risk cases,
since the risk of epidural bleeding is low. A larger sample is required to
correlate haemostatic variables and VTE.
P96
Fondaparinux Monitoring in a Dialysis Patient
with Heparin-induced Thrombocytopenia Type II
A. Kulić1 , V. Libek1 , A. Strugar1 , Z. Cvetković2 , & R. Marković3
1 Blood
Bank Department, CHC Zemun, Belgrade, Serbia; 2 Department
of Haematology, CHC Zemun, Belgrade, Serbia; 3 Departments
of Nephrology and Dialysis, CHC Zemun, Belgrade, Serbia
Introduction: Heparin-induced thrombocytopenia (HIT) is a
pro-thrombotic, immune-mediated adverse reaction that occurs
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
after exposure to unfractionated heparin (UFH) or low molecular
weight heparin (LMWH). Antibodies directed against the complex
PF4/heparin on platelet membrane are responsible for HIT. They lead
to intravascular platelet activation causing thrombocytopenia and/or
thrombosis. In chronic dialysis patients HIT frequency is low (3.9%
in literature) in newly diagnosed patients. Application of non-heparin
anticoagulant preparations, including fondaparinux, is necessary. Labo-
ratory monitoring of fondaparinux based on anti-Xa activity in dialysis
patients has not been sufficiently documented. We wanted to present
the application and dose adjustment of fondaparinux in dialysis patients
with HIT type II.
Methods: Blood samples were collected into 3 2% citrated vacuum tubes.
The presence of HIT antibodies was detected with immunoturbidimet-
ric assay (HIT-AbPF4-H HemosIL, IL ACL 300®). Anti-Xa assay was
calibrated with fondaparinux for the fondaparinux monitoring (ELITE
PRO® IL).
Results: Patient aged 56 years, in the last stage of kidney disease, 15 days
from the beginning of haemodialysis, developed the significant decline
in the platelets count 286 x 109 /L to 41x109 /L. Clinical suspicion for HIT
II was confirmed by a highly positive result for HIT-Ab (20.6 U/mL).
Dialysis was started using anticoagulation of 2.5 mg s.c. fondaparinux
with bicarbonate dialysis and low membrane permeability. It was not
possible to clear fondaparinux after fourth dialysis. Because of the threat
of bleeding due to the cumulative effect of the drug, fondaparinux
was administered intravenously before the dialysis procedure with high
efficiency bicarbonate haemodialysis. During the five-month application
of fondaparinux patient did not develop thrombotic or haemorrhagic
complications.
Conclusion: Fondaparinux does not require routine monitoring. Since
haemodialysis patients with HIT II belong to a specific category of
patients it is necessary to provide alternative anticoagulant protocols in
order to achieve adequate therapeutic levels of anticoagulation without
adverse effects.
P97
Thrombotic Microangiopathies: Transfusion Management
of Three Case Reports
M. M. Campos, V. Pishchanskyy, M. E. Ribeiro, M. J. Marques,
A. Fernandes, A. E. Silva & T. Araújo
Immunohaemotherapy (Head of Department: D. Espírito Santo),
Hospital Curry Cabral (HCC), Centro Hospitalar Lisboa Central, EPE,
Lisbon, Portugal
Introduction: Thrombotic thrombocytopenic purpura (TTP) and
haemolytic uraemic syndrome (HUS) are thrombotic microangiopathies
(TMA) with a poor prognosis and a high recurrence rate. The Transfu-
sion Medicine (TM) management is involved in diagnosis and therapy.
Our approach includes: blood bank testing and supply, haemostasis
laboratory and guidance for thromboprophylaxis. Plasma exchange
(PEX) was performed in other departments.
Methods: One patient with TTP and two with atypical HUS (aHUS).
Main therapy: PEX with solvent/detergent treated plasma as fluid
replacement.
Results: Case Report (CR) Synopsis (therapy procedures in HCC):
Three patients admitted with negative direct antiglobulin haemolytic
anaemia with schistocytes, thrombocytopenia and acute renal injury.
Autoimmune, HIV, HCV and acute HBV/CMV/EBV markers were neg-
ative; normal clotting screen. Enoxaparin was started when platelet
(PLT) count improved. CR 1: A 20-year-old Caucasian woman, G0P0,
with neurologic manifestations (aphasia and left haemiparesia followed
by complete remission), anti-ADAMTS13 positive (84.01 U/mL) that
was diagnosed as TTP. Epilepsy treated with sodium valproate until 9
years of age. Haemoglobin (Hb) decreased to 5.7–7.8 g/dL and PLT to
10–12 x 109 /L, haptoglobin (Hp) <0.07 g/L and lactate dehydrogenase
(LDH) increased to 929–1007 U/L. A total of 5 PEX, 72 U of plasma
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society

and 1 red cell concentrate (RCC) were realised. Normal PLT count at
12th day and Hb: 11.9 g/dL at 29th day; full recovery after 1 month. CR
2: A 32-year-old Black woman, G2P1A1, in the 1st day post caesarean
section with aHUS. Four relatives suffered preeclampsia. Hb, PLT, Hp
and LDH reached 4.4 g/dL, 22 x 109 /L, 0.08 g/L and 6290 U/L respec-
tively. Renal biopsy (RB): focal segmental glomerulosclerosis. Nine PEX
were carried out; she was transfused with 6 RCCs and 240 U of plasma.
PLT and enzyme profile recovered 7 days post PEX onset and renal func-
tion only 33 days past; Hb was 11.9 g/d. at 57th day. CR 3: A 35-year-old
Caucasian man with addictive history (cocaine, heroin) and deficiency
of factor H and C3 diagnosed as aHUS. Worse results as follows: Hb
5.1–7.0 g/dL, PLT 63–115 x 109 /L, Hp < 0.07 g/L and LDH 1287–1572
U/L. RB: glomerular ischemic lesions without thrombosis. A total of
198 PEX, 3212 U of plasma and 3 RCCs were performed in 14 months.
Relapse justified increment of PEX and plasma infusion. An adverse
reaction occurred after 1 RCC (respiratory distress). Hb: 13.9 g/dL and
PLT: 196 x 109 /L at 14th month.
Conclusions: CR 1 seems idiopathic. Pregnancy can be a triggering
event for aHUS in CR 2. In CR 3 the association of factor H deficiency
and cocaine use with aHUS remains possible. PEX removes antibodies,
ultra-large von Willebrand factor multimers and mutated proteins. We
use plasma to provide normal ADAMTS13 and to replace complement
regulators with mutations by functional proteins. TM Services must
ensure provision of blood components and derivatives for transfusion
in these rare but severe disorders, a resourceful laboratory performance
and a multidisciplinary interface with Intensive Care Unit, Nephrology
and other departments.
P98
Management of Prosthetic Valve Thrombosis during
Pregnancy
K. Schulte1,2 , R. Attia1 , X. Luo1 & V. Bapat1
1 Department of Cardiothoracic Surgery, Guy’s and St Thomas’ Hospital,
London, UK; 2 Charité Berlin, Germany
Objectives: To highlight the potential complications of switching from
warfarin to low molecular weight heparin anticoagulant in the setting of
mechanical heart valve during pregnancy. We discuss heart valve throm-
bosis, its management and how extracorporeal membrane oxygenation
(ECMO) may play a role in resuscitation for surgery.
Case Description: A 27-year-old pregnant woman (at 28 weeks ges-
tation) with a 6-year old mechanical mitral valve presented to local
emergency department complaining of severe shortness of breath. At
the start of pregnancy the patient had discontinued warfarin in-favour
of low molecular weight heparin anticoagulation as replacement ther-
apy, self-administering subcutaneous therapeutic enoxaparin injections
twice daily. Her condition quickly deteriorated after admission and she
was referred for extracorporeal membrane oxygenation (ECMO), inten-
sive care support, assessment for possible caesarean section and delivery
of the foetus. Transoesophageal echocardiogram confirmed prosthetic
valve thrombosis and the patient was converted from veno-venous (VV)
ECMO to veno-arterial (VA) ECMO, stabilised for 5 hours and taken
to theatre for emergency mitral valve placement, this time with a tissue
valve. Foetal heart sounds were undetectable upon initial arrival and the
decision was made to medically induce the deceased foetus several days
after the operation. The patient postoperatively remained on ECMO for
7 days and was subsequently discharged well 25 days post-op, remaining
well at 1-year follow-up.
Conclusion: Anticoagulation during pregnancy is a complex problem
and requires specialist haematological, obstetrics and cardiac team input.
Regular monitoring with anti Xa levels is mandated. In this case pros-
thetic valve thrombosis was managed effectively with a combination
of VV-VA ECMO. This provided an effective alternative approach to
stabilise high-risk patients before emergent cardiac surgery. We aim to
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society
Abstracts of the 16th Annual NATA Symposium 53
discuss problem of prosthetic valve thrombosis, anticoagulation in preg-
nancy and using ECMO in this setting.
P99
Tissue Factor and the Risk of Thrombosis in Patients
with Polycythemia Vera
G. Gadomska1 , J. Boinska1 , K. Stankowska1 , M. Michalska1 ,
K. Góralczyk1 , R. Wieczór1 , B. Ruszkowska-Ciastek1 & D. Rość1
1 Department of Pathophysiology Collegium Medicum, Bydgoszcz,
Poland; 2 Clinic of Haematology and Haematological Malignancies
Diseases, Dr J. Biziel University Hospital No. 2, Bydgoszcz, Poland
Introduction: Polycythaemia vera is a myeloproliferative neoplasms
(MPNs), a clonal disorder characterised by the overproduction of mature
red blood cells in the bone marrow. The aim of this study was to evaluate
the potential of activation of extrinsic pathway blood coagulation in
patients with polycythaemia vera.
Methods: The study involved 52 patients with polycythaemia vera F/M
28/24 (mean age 61.5 years). The control group consisted of 30 healthy
volunteers F/M 19/11 (mean age 50 years). Plasma concentrations of TF,
TFPI, thrombin-antithrombin complexes (TAT), D-dimer and activity
of TF and TFPI were performed by Enzyme Linked Immunosorbent
Assay (ELISA), however the activity of antithrombin was measured
in an automated coagulometer CC-3003 apparatus and reagents were
purchased from Bio-Ksel Co., Poland.
Results: In the study we observed a significantly higher concentra-
tion and activity of TF and TAT complexes, D-dimer in patients with
polycythaemia vera relative to controls (p < 0.0004; 0.0039, 0.01, 0.01-
respectively). Patients with polycythaemia vera had also a significantly
lower concentration of TFPI and antithrombin activity (p = 0.0463;
0.01-respectively).
Conclusion: In patients with polycythaemia vera enormous intensive
activation of extrinsic pathway of coagulation was observed. Higher
levels of TAT complexes and D-dimer confirm this hypothesis.
P100
Maternal Genetic Risk Factors of Thrombophilia: 1691G>A
FV, 20210G>A FII, 677C>T MTHFR Mutations
and Recurrent Pregnancy Loss in Bosnian Women
G. Adler1 , E. Mahmutbegovic2 , A. Valjevac3 , A. Pawinska-Matecka4 ,
A. Garstka1 , A. Begovic1 & E. Czerska4
1 Department of Gerontobiology, Pomeranian Medical University,
Szczecin, Poland; 2 Institution of Health Protection of Women
and Motherhood Canton Sarajevo, Sarajevo, Bosnia and Herzegovina;
3 Laboratory for Molecular Medicine, Center for Genetics, Medical
Faculty, University of Sarajevo, Sarajevo, Bosnia and Herzegovina;
4 Central Laboratory, Regional Hospital, Szczecin, Poland
Introduction: Pregnancy loss is a major problem of women’s health.
About one fifth of all women worldwide have suffered at least one
spontaneous pregnancy losses, and 1/20 two or more. Routine
gynaecological, endocrine and cytogenetic diagnostics could not
clarify the reason up to 40% of cases of pregnancy losses worldwide.
Recently, the heritable factors of thrombophilia that may predispose to
microthrombosis mainly in trophoblast or placenta leading to obstet-
rical complications attracts a great attention. We aimed to determine
allele frequencies of the 1691G > A FV, 20210G > A FII, 677C > T
MTHFR mutations in Bosnian women who experienced at least one
pregnancy loss.
Methods: We prospectively recruited 50 women with recurrent preg-
nancy loss mean age 33.0 (±5.4) years and 30 healthy controls mean
age 32.8 (±6.3) years from Institution of Health Protection of Women
and Motherhood (Sarajevo, Bosnia and Herzegovina). Following
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
54 Abstracts of the 16th Annual NATA Symposium
DNA isolation from buccal swabs, PCR-RFLP for 20210G > A FII and
677C > T MTHFR and real-time PCR for 1691G > A FV was performed.
We obtained a 100% concordance between the genotyped duplicate
samples for the SNP.
Results: From our study we identified 5 GA heterozygotes and none
AA homozygotes for 1691G > A FV, 1 heterozygote GA and none AA
homozygotes for 20210G > A PT and 15 CT heterozygotes and 5 TT
homozygotes for 677C > T MTHFR in women with recurrent preg-
nancy loss. In control group were none both GA heterozygotes and
AA homozygotes for 1691G > A FV, 2 heterozygotes GA and none
AA homozygotes for 20210G > A PT and 12 CT heterozygotes and 3
TT homozygotes for 677C > T MTHFR. Frequencies of allele 1691A,
20210A and 677 T allele in women with recurrent pregnancy loss were:
8.3%, 3.3% and 41.7%, and in control group: 0%, 3.3% and 30.0%, respec-
tively.
Conclusion In summary, this study provides first genetic data related to
prevalence of mentioned mutations in women from Bosnia and Herze-
govina with recurrent pregnancy loss. Within the group of women with
pregnancy losses found the positive correlation between the frequency
of allele 1691A FV and the number of pregnancy loss (r = 0.43) Further
studies with larger samples are warranted.
P101
Dramatic Decrease of Prothrombin Level during
Thrombolysis in Acute Myocardial Infarction
T. M. Platonova1 , V. O. Chernyshenko1 , D. S. Korolova1 ,
T. M. Chernyshenko1 & O. Parkhomenko2
1 Protein Structure and Functions Department, Palladin Institute
of Biochemistry of NAS of Ukraine, Kyiv, Ukraine; 2 National Scientific
Center “M.D. Strazhesko Institute of Cardiology MAS of Ukraine”, Kyiv,
Ukraine
Introduction: It has been shown that during thrombolytic therapy
there is an increase in thrombin generation measured by prothrombin
Transfusion Medicine, 2015, 25, Suppl. 1, 13–54
fragment 1 + 2 level (up to 3nM). But the total level of prothrombin in
blood plasma of patients during thrombolysis is not being measured.
Aim: The aim of our work was to analyse the level of prothrombin in
the blood plasma of patients with acute myocardial infarction at 2 hours,
3 and 7 days after the thrombolysis by streptokinase (n = 45) accompa-
nied with intravenous administration of anticoagulants: high-molecular
weight heparin (HMWH) and low-molecular weight heparin (LMWH).
Methods: Total prothrombin level was measured using the prothrombin
activator from the venom of Echis multisquamatis that could activate
all forms of prothrombin. Activator was added to the sample of blood
plasma and generated thrombin activity was measured by cleavage of
chromogenic substrate S2238. Donors’ blood plasma was used as a
control probe.
Results: The prothrombin total level in the blood plasma of patients with
myocardial infarction was normal (95 ± 11%). During thrombolysis and
concomitant therapy with LMWH, there was a decrease in the plasma
levels of prothrombin (median 55%; min 40%, max 80%, p < 0.001).
Whereas less obvious change was observed in the case of HMWH
(median 84%; min 56%, max 110%, p < 0.001). The level of prothrombin
was recovered after three days: 0.087 ± 0.017 mg/mL for LMWH group
and 100 ± 13% for HMWH group.
Statistical analysis in “Statistica 7” was used to calculate the correlations
of total prothrombin level. It was found that total prothrombin level
was distinctly correlated with the type of anticoagulant that was used:
r = -0.70, p < 0.001. This parameter was also correlated with the level of
soluble fibrin (SF) – the main marker of acute disorders of coagulation
system. Distinct correlation between SF and total prothrombin level was
founded after 3 and 7 days after start of therapy (r = -0.55 and r = -0.70
respectively, p < 0.05).
Conclusion: Thus the drop in of total prothrombin level in blood plasma
during thrombolysis was observed. It was strongly dependent to the type
of anticoagulant therapy and was not obvious in the case of concomitant
therapy with HMWH so both thrombin and factor Xa were inhibited.
The usefulness of total prothrombin level estimation was confirmed by
its statistic correlation with the level of soluble fibrin.
© 2015 The Authors
Transfusion Medicine © 2015 British Blood Transfusion Society