We previously validated and implemented criteria for auditing anaesthesiologists with intraoperative transfusion based on low median blood loss of the surgical procedure or absence of anaemia before transfusion. However, obstetrical cases were excluded during implementation, as the peripartum blood management protocol does not include haemoglobin determinations, matching American College of Obstetricians and Gynaecologists recommendations. For non-obstetrical surgery, intraoperative transfusion is associated with an increased probability of postpartum transfusion. Because of the obstetrical transfusion approach, we hypothesized the opposite relationship between intrapartum and postpartum transfusion. The retrospective cohort study included all 30 160 patients who delivered at the University of Iowa January 2013 through March 2025. Any RBC administration during anaesthesia care reduced the odds of later transfusion (odds ratio 0.14, 99% confidence interval (CI) 0.11%-0.18%). Single-unit RBC administration during anaesthesia reduced such odds (0.09, 99% CI 0.06%-0.11%), as did multiple-unit transfusion (0.18, 99% CI 0.13%-0.24%). McNemar tests had Bonferroni-adjusted p-values <0.0001. While antepartum anaemia (haemoglobin <11 g/dL) increased the probability of transfusion by 7.41% (standard error 0.43%) outside of anaesthesia care, the RBC transfusion decision during anaesthesia care was less influenced by anaemia, 1.52% (0.22%), p < 0.0001. Many (59%, 99% CI 50%-69%) RBC units started during anaesthesia care were administered to patients who were not anaemic (haemoglobin ≥11 g/dL) at admission. Most patients with single-unit RBC transfusion and blood loss <2500 mL had stable haemodynamics. Unlike several categories of non-obstetrical procedures, RBC transfusion during anaesthesia care for delivery was associated with a reduced probability of postpartum RBC transfusion. A reasonable approach for blood bank auditing of anaesthesiologists' obstetric RBC transfusion decision-making would be to review cases when RBC were administered, there was blood loss <2500 mL, no subsequent transfusion, and discharge haemoglobin ≥9 g/dL.
Assess the safety and efficacy of restrictive transfusion in haemato-oncological patients undergoing autologous haematopoietic stem cell transplantation (AHSCT). Restrictive transfusion is increasingly advocated within transfusion medicine to prevent over-treatment, lower transfusion-related adverse events and decrease healthcare costs. Yet there is a paucity of evidence regarding safe restrictive transfusion strategies in AHSCT patients. Double-unit transfusion at a haemoglobin threshold of 8 g/dL (i.e., liberal transfusion) is compared to single-unit transfusion at a haemoglobin threshold of 7 g/dL (i.e., restrictive transfusion) by means of an interrupted time series study. RBC utilisation, survival and the occurrence of complications were assessed for the initial hospitalisation period and at the hundredth day following AHSCT. A group of 28 liberally transfused patients is compared to 18 restrictively transfused patients. Restrictively transfused patients received a median of 0.0 RBC units (IQR 0.0-1.0) and liberally transfused patients 2.0 RBC units (IQR 0.0-4.0) during hospitalisation (U = 127.5, p = 0.002). The number of RBC concentrates administered by day +100 remained significantly lower for restrictively (0.0 units, IQR 0.0-3.0) as opposed to liberally (2.0 units, IQR 0.0-4.0) transfused patients (U = 168.5, p = 0.026). Survival and readmission rates did not differ significantly between both groups. The most prevalent complications, regardless of the applied transfusion protocol, included mucositis, fever of unknown origin and various infections. Restrictive transfusion through combined lowering of the haemoglobin trigger to 7 g/dL and single-unit transfusion effectively decreases RBC utilisation in a homogenous cohort of haemato-oncology patients undergoing AHSCT without hampering safety.
Platelet transfusion is essential in managing thrombocytopenia in hemato-oncology patients. This study aimed to determine the prevalence of platelet refractoriness (PR) and to evaluate the efficacy of crossmatch-compatible single-donor platelet (SDP) transfusions in patients with suspected platelet refractoriness. A two-year quasi-experimental study comprised adult and paediatric hemato-oncology patients with two consecutive low corrected count increment (CCI) responses (<7500/μL) following SDP transfusions. Refractory patients with non-immune causes were tried to be excluded as far as possible. Platelet crossmatching was performed using solid-phase red cell adherence (SPRCA) technology. One-hour post-transfusion CCI and percentage platelet recovery (PPR) were evaluated between crossmatch-compatible and incompatible transfusions. Statistical analyses included descriptive statistics as mean ± standard deviation (SD), median with interquartile range (IQR), or frequencies (%). Multivariate regression analysis was used to identify predictors of transfusion response. Among 272 SDP transfused patients, 142 (52.2%) were refractory and of them, 101 were eligible for platelet crossmatching. Of the 166 SDP transfusions, 63.4% were crossmatch incompatible. Crossmatch-compatible transfusions yielded significantly higher mean CCI (17 788 vs. 11 913, p = 0.001) and PPR (44.8% vs. 28.7%, p < 0.001). Crossmatching demonstrated high sensitivity (84.8%) and NPV (86.4%) for detecting inadequate responses. Multivariate analysis identified platelet compatibility and age as significant predictors of transfusion efficacy. Crossmatch-compatible platelet transfusions significantly improve post-transfusion CCI and PPR in alloimmunised hemato-oncology patients. Crossmatch compatibility and patient age were identified as two independent predictors of adequate early platelet transfusion response (1-h CCI, PPR and platelet increment).
This study evaluated the safety, efficacy, and guideline adherence of home transfusions at a single institution over nearly a decade. In Japan, demand for home-based red blood cell (RBC) transfusions is increasing due to population aging and promotion of community-based care. Although national guidelines were issued by the Japanese Society of Transfusion Medicine and Cell Therapy (JSTMCT) in 2017, evidence regarding their real-world application and safety remains limited. We retrospectively reviewed 1007 planned RBC transfusion procedures in 181 patients (median age 81 years, range 37-97) between March 2016 and September 2024 in suburban Tokyo. Data included patient characteristics, transfusion details, haemoglobin (Hb) levels, adverse events, and JSTMCT guideline compliance. Paired Hb values were analysed using the Wilcoxon signed-rank test. Malignancy was the most common underlying condition (173/181 patients, 95.6%), with haematological disorders predominant (102/181, 56.4%). Of 1007 planned procedures, 48 (4.8%) were cancelled. The median number of procedures per patient was 7 (range 1-232). Among 410 procedures with paired Hb values within 15 days, Hb increased significantly (median 6.8 g/dL pre- vs. 7.4 g/dL post-transfusion, p < 0.05). Mild adverse reactions occurred in 0.31% (3/959), lower than the JSTMCT-reported hospital rate of 0.64%. Compliance with JSTMCT guidelines was highest for caregiver presence (100%) but lowest for initial hospital-based transfusion (74.6%). Home-based RBC transfusions demonstrated excellent safety and efficacy profiles with lower adverse reaction rates than hospital-based transfusions. This study suggests that the JSTMCT guideline revisions should consider real-world practices, particularly initial transfusion requirements and hospital-clinic collaboration.
To examine if transfusion-associated circulatory overload (TACO) shows a circadian pattern. Non-urgent transfusions often take place during the night-time. This interferes with patient rest and patient monitoring. Also, transfusion reactions like TACO may be more likely during the night for pathophysiologic reasons. Using New Zealand haemovigilance and transfusion data for the three-year period between January 2022 and December 2024, we compared the daytime and night-time rates of TACO and two other transfusion reactions (allergic reactions and transfusion-associated hypotension, TAH). A quarter of transfusion episodes happened during the night-time. The night-time TACO rate was twice the daytime rate (p = <0.0001). This was also seen in males alone (p = <0.0001), but not in females. With allergic reactions, the daytime and night-time rates were similar. With TAH, it appeared to be higher, but our TAH numbers are small. The night-time TACO rate was higher than the daytime rate. As with cardiogenic acute pulmonary edema and other cardio- and cerebro-vascular conditions which are more frequent at night, this may involve biological clocks, external stressors (e.g. recumbency and transfusion), and individual risk factors. This is yet another reason to avoid overnight transfusions unless urgently needed.
There is an urgent need to improve transfusion services in the National Health Service. Current transfusion practice remains largely paper-based, labour-intensive and error-prone, contributing to rising adverse events. Inappropriate blood use is common, measures for the avoidance of transfusion are underutilised and both blood wastage and shortages are at unacceptable levels. There have been many national initiatives to improve transfusion practice over the last 25 years, but the implementation of their recommendations has been poor, as evidenced by the disturbing results of the annual national audits of compliance with the National Institute for Health and Care Excellence Quality Standards for Blood Transfusion. This article discusses these issues and argues for investment in the transfusion workforce, a modernised digital infrastructure and greater oversight of transfusion practice. It is now time to renew efforts to modernise transfusion practice to standards of safety, efficiency and clinical effectiveness, which our patients should reasonably expect.
Pulmonary complications of transfusion are a leading cause of morbidity and mortality. Transfusion-associated circulatory overload (TACO) is the most common, whereas transfusion-related acute lung injury (TRALI) is less frequent but potentially fatal. To describe a pediatric case with overlapping features of TACO and TRALI following platelet transfusion and to highlight diagnostic and management challenges. We report the case of a 15-year-old patient with acute myeloid leukemia who developed acute respiratory compromise after platelet transfusion. Clinical findings, laboratory data (including pro-BNP), imaging, and immunologic investigations were evaluated. Elevated pro-BNP levels and signs of fluid overload were consistent with TACO. However, chest radiography demonstrated non-cardiogenic pulmonary edema, and pre-existing pulmonary involvement supported a diagnosis of type II TRALI. Management included immediate cessation of transfusion, oxygen therapy, and comprehensive evaluation with cytokine profiling, antibody screening, and advanced immunologic testing. This case illustrates the diagnostic complexity of transfusion-related pulmonary complications, particularly when TACO and TRALI features overlap, and underscores the importance of a multidisciplinary approach to management and investigation.
Blood loss during the surgical management of craniosynostosis surgery is common and frequently requires blood transfusion. Interventions such as minimally invasive surgical approaches have been developed to minimise blood loss, given the morbidity of haemorrhage and the adverse effects of transfusion. This study aimed to identify and characterise the most impactful studies relevant to blood loss and transfusion in surgery for craniosynostosis. Articles were searched and screened using the Web of Science (WoS) core collection database using keywords related to "blood loss," "transfusion," and "craniosynostosis." The most cited 100 relevant articles published in the English language were selected. Extracted data included WoS bibliographic and citation metrics, study characteristics and design, and keywords. Research theme and Level of Evidence (Oxford Centre of Evidence-Based Medicine) were ascertained. In-built tools on Google Sheets were used to perform and present descriptive statistics with bibliometric data and a citation-based review. The search returned 299 articles. The most cited relevant 100 articles were published between 1993 and 2022. The USA published the most articles (65%), followed by England (7%) and Canada (4%). The Journal of Craniofacial Surgery published the most articles (25%), followed by the Journal of Neurosurgery Paediatrics (17%) and Plastic and Reconstructive Surgery (10%). The most common research area (as categorised by WoS) was surgery (n=76), paediatrics (n=36), and neurosurgery (n=33). The most common research themes were endoscopic or minimally invasive interventions (31%), blood loss and transfusions (27%), and pharmacological interventions (21%). Most articles had a Level of Evidence of III (49%) or IV (22%). This novel analysis and review highlights the most influential articles in this field, as well as key themes that have shaped current clinical practice. These insights may help clinicians, researchers, and policymakers who continue to evaluate the surgical management of craniosynostosis.
Bedside transfusion errors, especially positive patient identification (PPID), are a risk to patient safety. Bedside electronic transfusion checks (BETC), using barcode-enabled personal digital assistants (PDAs), are recommended to improve safety and efficiency. This study assessed staff satisfaction with BETC versus manual transfusion checks in three large London hospitals. The surveys aimed to compare clinical staff satisfaction with BETC versus the manual system. A cross-sectional survey was conducted immediately after training and 6 months after routine BETC use. The initial (21 questions) and follow-up (15 questions) surveys assessed usability, accuracy, workflow efficiency and patient care impact. Responses were collected via Microsoft Forms and analysed using descriptive statistics and logistic regression, adjusting for job role, experience and hospitals. A total of 2085 staff completed the initial survey (55% response) and 514 the follow-up (13%), predominantly nurses (75%). For group and screen (G&S) labelling, ratings of 'ease of use' and 'accuracy' improved significantly between surveys, while perceived impact on reducing mislabelling remained consistently high (96.2% vs. 94.7%). Compared with manual checks, BETC was rated significantly by clinicians for ease of use (89% → 94%) and accuracy (89% → 95%; both p < 0.001). Improvements were also observed for the time saved by clinical staff (75% → 89%), patient care (77% → 89%), fewer nurses required (79% → 91%) and traceability (80% → 87%), all statistically significant (p < 0.001). BETC was associated with significantly greater clinical staff satisfaction than manual transfusion checks, providing large-scale evidence for their adoption to enhance transfusion safety, efficiency and staff experience.
ABO incompatibility is common in allogeneic haematopoietic stem cell transplantation (HSCT) and may delay erythroid recovery and prolong transfusion support. Data correlating post-transplant isoagglutinin kinetics with transfusion dependency is limited. We retrospectively analysed ABO-incompatible allogeneic HSCTs performed between June 2008 and December 2023. Patients were classified as major, minor or bidirectional incompatibility. Serial Immunoglobulin M (IgM) and Immunoglobulin G (IgG) anti-A and anti-B isoagglutinin titres were monitored post-transplant. Time to isoagglutinin disappearance, donor red blood cell (RBC) appearance and associations with packed red blood cell (PRBC) and single donor platelet (SDP) transfusion requirements were evaluated. Among 459 allogeneic HSCTs, 183 (39.9%) were ABO-incompatible. Median isoagglutinin disappearance was 28 days in major and 38.5 days in bidirectional incompatibility, with delayed donor RBC appearance in the latter. Anti-A isoagglutinins persisted longer than anti-B. Persistent isoagglutinins correlated with increased early PRBC and SDP transfusion requirements. Isoagglutinin kinetics vary by ABO incompatibility type and are associated with early transfusion dependency after HSCT.
Red-blood-cell (RBC) transfusion is one of the most frequent interventions in critical care patients. While patients with acute cardiac conditions are more likely to receive transfusions at higher haemoglobin thresholds than other critically ill patients, data on RBC transfusion practice for critically ill patients with pre-existing cardiac conditions are scarce. Using the International Point-Prevalence Study of Intensive-Care Unit Transfusion Practices cohort, weighted logistic regression investigated the association between the RBC units transfused and the primary composite outcome of 28-day mortality, new-onset acute kidney injury or ventilatory weaning failure. Interactions with cardiac history (acute coronary syndrome and/or heart failure) were tested. Cardiac history was present in 746 of 3643 patients (20%) and 894 of 3643 (25%) received at least one RBC unit. Transfusion rates were similar in patients with and without cardiac history (25% vs. 24%; p = 0.51). Among transfused patients, median nadir haemoglobin during ICU stay was slightly higher in those with cardiac history (7.6 g/dL vs. 7.4 g/dL respectively; p = 0.007), whereas stated haemoglobin transfusion threshold did not statistically differ (8.5 g/dL vs. 8.0 g/dL; p = 0.11). Each additional RBC unit increased the odds of the composite outcome in the whole cohort (2.18, 95% CI 1.85–2.56, p < 0.0001), without interaction with cardiac history (p = 0.44). RBC transfusion was commonly and similarly prescribed in critically ill patients with or without cardiac history. Each additional unit was associated with a worse outcome with no evidence of differential effect due to cardiac history. NL9049 (Dutch Trial Register), registered on 16 November 2020. [Image: see text] The online version contains supplementary material available at 10.1186/s13054-025-05745-5.
Bedside electronic transfusion checks (BETC) enhance transfusion safety by reducing errors associated with manual processes. Despite national recommendations, BETC adoption in the United Kingdom remains limited. This study reports on the implementation of BETC at four hospitals at Barts Health NHS Trust, aiming to share insights on the implementation process. The main implementation was split into three phases: (1) pre-pilot, (2) pilot and (3) main implementation (2022-2025). Staff surveys on training satisfaction and key performance indicators (KPIs) on transfusion activity were used to evaluate the uptake of the BETC system. Statistical process control (SPC) charts were used to identify trends, variation and patterns in the data following the implementation of BETC. A total of 5079 staff were trained and 404 personal digital assistant (PDA) devices deployed across four hospitals. Early implementation highlighted that training 60% of staff was insufficient for optimal system use, increasing this threshold to 80% improved adoption. BETC was initially more commonly used for blood administration than group and screen (G&S) sample labelling. Over time, increased usage of BETC for G&S labelling correlated with a marked reduction in sample rejection rates across all sites. Staff reported high satisfaction with training, with 99.5% rating it positively. Early adopters played a pivotal role, but achieving widespread adoption required extended training and support. Addressing technical and workflow barriers, coupled with mandatory system use, could enhance the speed of impact of BETC. These insights offer guidance for future adopters aiming to improve transfusion safety and efficiency.
To evaluate laboratory investigations for micronutrient deficiencies as the cause of anaemia prior to first-time red blood cell transfusions in the medical emergency department (ED) of a large academic hospital. The ED is often the first point of contact for acutely ill anaemic patients, yet patient blood management principles are underutilised. Because micronutrient deficiencies are common, treatable causes of anaemia, they should be screened for to guide targeted treatment and reduce unnecessary transfusions. We conducted a retrospective cross-sectional study of 198 adult patients receiving first-time transfusions in the medical emergency unit at Groote Schuur Hospital, South Africa, between April and October 2023. Laboratory investigations for iron, vitamin B12, and folate deficiencies were analysed and stratified by pre-transfusion mean corpuscular volume (MCV). Iron deficiency was evaluated using three locally used criteria. Data about haematinic supplementation were also collected. Only 29% of patients received a full micronutrient deficiency workup, while 39% had no testing. Iron deficiency was the most frequent abnormality, and up to 30% of these patients had normocytic indices. Iron supplementation rates were high, but many patients without iron deficiency also received iron. The ED encounter should be used as an opportunity to initiate basic micronutrient deficiency screening for anaemia, regardless of MCV.
Haematology is at a crossroads, divided between haemato-oncology and the disparate disciplines collectively known as 'non-malignant' haematology. This latter term is a misnomer that devalues a spectrum of complex, life-threatening conditions and contributes to workforce shortages and research inequities. This article argues for the formal adoption of the term Medical Haematology to redefine this domain. We chart its central role across medicine, from guiding anticoagulation, transfusion and thrombosis care across specialties to addressing global health challenges. We highlight its pioneering contributions to molecular medicine and immunotherapy, exemplified by gene therapy for haemophilia and the repurposing of chimeric antigen receptor T cells for autoimmune disease. Finally, we present a forward-looking blueprint involving establishment of 'Blood Teams', revamping educational curricula and championing equity to secure the speciality's future. Embracing Medical Haematology is a strategic imperative to reflect the life-threatening nature of many conditions within the speciality, attract trainees, rebalance research priorities and firmly re-establish haematology's indispensable role at the heart of modern medical practice.
Blood transfusion remains a cornerstone in the management of sickle cell disease (SCD); however, it is frequently complicated by red cell alloimmunisation. A significant debate persists within the scientific community regarding the optimal strategy to mitigate this risk: the traditional, pragmatic approach of serologic phenotyping versus molecular genotyping, which is technically superior yet more resource-intensive. This mini-review aims to map the framework of this scientific debate and synthesize current evidence through a dual methodology. A scientometric analysis was conducted on 224 articles indexed in Scopus and Web of Science using the Bibliometrix package for R, followed by a structured narrative review of 26 selected studies. The scientometric findings confirm growing interest in this topic, identifying two distinct yet interconnected research clusters that reflect the ongoing dialectic between phenotyping and genotyping, with the latter emerging as a 'hot topic' over the past decade. The narrative synthesis highlights a predominance of evidence supporting genotyping as the most accurate approach to preventing alloimmunisation, particularly given the high prevalence of RH system variants in individuals with SCD. In contrast, cost-effectiveness analyses and implementation studies underscore substantial financial and logistical barriers that favour a more pragmatic, stepwise approach. We conclude that the future of transfusion safety in SCD does not lie in a binary choice but rather in a synergistic and stratified integration of both strategies. Implementing protocols that target genotyping for high-risk patients, while simultaneously optimising the use of extended phenotyping, represents the most promising pathway to balance safety, cost and accessibility-ultimately ensuring the best possible transfusion therapy for this vulnerable population.
Postpartum haemorrhage (PPH) causes ~70 000 maternal deaths annually, making it one of the leading causes of preventable maternal mortality. This study evaluated the effectiveness of individualised goal-directed bleeding management (GDBM) in severe PPH in our centre with unique geographical challenges. We conducted a retrospective analysis of severe PPH requiring massive transfusion over 1 years. Patients were classified into a fixed ratio (1:1:1) massive transfusion protocol (Group 1) and GDBM (Group 2). Study outcomes included blood utilisation, persistence of coagulopathy after resuscitation and mortality. The target was to keep a fibrinogen level of >200 mg/dL during the resuscitation. Thromboelastography was used to guide GDBM, and data were analysed using mean, median, percentage changes, chi-square test, student t test, and Mann-Whitney U-test. Out of 96 patients (42 were in Group 1 and 54 in Group 2), GDBM led to increased cryoprecipitate utilisation (410 vs. 297 units) and a higher post-resuscitation fibrinogen value (252 [185.32-426.42] mg/dL vs. 204.6 [154.5-274.05] mg/dL, p = 0.02). The cryoprecipitate turnaround time was improved (41 vs. 73 min, p < 0.001) with GDBM ensuring timely administration. Increased fibrinolysis activity was observed in 24% of the patients in TEG. The persistence of coagulopathy after deactivation of MTP was lower in GDBM (7.4% vs. 26.19%). Out of the three patients who did not survive, two were in Group 1. Individualised GDBM optimises blood utilisation, reduces turnaround time and improves coagulopathy in PPH and needs to be prioritised.
Fragmentation across operations, data systems, governance, and regulation leaves many blood supply networks ill-equipped to provide timely, equitable, and crisis-resilient transfusion support. Public health emergencies, such as COVID-19 and natural disasters, have exposed the human and economic costs of these structural flaws, and how variability in practice about who can see and share data still impedes coordination even when the overall blood inventory is adequate. This Critical Perspective examines blood supply coordination challenges in high-income countries, focusing on governance structures, operational isolation, regulatory inconsistencies, and data system incompatibilities. We analyze evidence from crisis events including pandemics, natural disasters, and mass casualty incidents to illustrate coordination failures and successful response models. The review synthesizes peer-reviewed literature identified through PubMed searches (January 2010 - September 2025), supplemented by regulatory documents, industry reports, and government policy analyses from blood regulatory agencies in the United States, United Kingdom, Canada, and other high-income countries. Effective solutions require coordinated interventions across multiple domains rather than isolated or localized improvements. Priority areas include governance structures that enable cross-institutional collaboration, interoperable data systems with standardized sharing protocols, regulatory frameworks that incentivize coordination, and value-based reimbursement models that reward system-wide performance.
Not applicable.
Whole-blood transfusion has recently gained favor in the management of severe hemorrhage; however, data from large clinical trials evaluating its clinical effectiveness and safety are lacking. We conducted a pragmatic, phase 3, multicenter, unblinded, randomized, superiority trial across 10 air ambulance services in England. Patients with major traumatic hemorrhage who were attended by a participating air ambulance service were randomly assigned to receive either whole-blood transfusion (up to 2 units) or standard care with blood components (up to 2 units each of red cells and plasma) before arrival at the hospital. The primary outcome was a composite of death from any cause or massive transfusion (≥10 units of blood components or products) within 24 hours after randomization. A total of 942 patients underwent randomization. After the exclusion of participants with nontraumatic hemorrhage or traumatic cardiac arrest, 616 were included in the analysis (314 in the whole-blood group and 302 in the standard-care group). A primary-outcome event occurred in 48.7% of the participants in the whole-blood group and in 47.7% of those in the standard-care group (relative risk, 1.02; 95% confidence interval, 0.80 to 1.31; P = 0.84). The incidence of death from any cause at all time points, massive transfusion, and other secondary outcomes appeared to be similar in the two groups. Prothrombin times were above the normal range in 40.7% of the participants in the whole-blood group and in 30.5% of those in the standard-care group. More serious adverse events occurred in the standard-care group than in the whole-blood group (37 and 31, respectively). The incidence of thrombotic events appeared to be similar in the two groups. Among participants with life-threatening hemorrhage, prehospital transfusion of 2 units of whole blood was not superior to standard care in reducing the risk of death or massive transfusion within 24 hours. (Funded by NHS Blood and Transplant and others; ISRCTN Registry number, ISRCTN23657907.).
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