Clinical Pathology Abstracts, 10/16

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Risk factors for transfusion in cesarean section deliveries at a tertiary hospital

Obstetrical hemorrhage is a major cause of morbidity and mortality in young women and may be difficult to predict. In some regions of the world, postpartum hemorrhage (PPH) may account for up to 25 percent of maternal deaths. Many studies have focused on the predictors of PPH before delivery. The authors of this study determined which variables were associated with various transfusion levels after cesarean delivery. They conducted a retrospective study at a tertiary hospital from 2006 to 2013. A total of 271 patients who received blood transfusions for PPH during a cesarean section and up to 24 hours after delivery composed the transfusion study group. This group was then stratified into three subgroups: fewer than five units (mild), five to 10 units (moderate), and 10 or more units (massive). The authors also established a control group of 271 women who had PPH but did not require transfusion. The blood transfusion rate was 0.53 percent. The study showed that assisted reproductive technologies were a risk factor for mild and moderate transfusion, while placenta previa was a risk factor for moderate transfusion. Pernicious placenta previa was a risk factor for all transfusion groups. The data also showed that more women were treated with intrauterine balloon pressure and uterine compression sutures in the mild, moderate, and massive transfusion groups than in the nontransfusion group. The authors concluded that assisted reproductive technologies, placenta previa, and pernicious placenta previa are significant predictors of transfusion levels. This information may be useful when establishing multidisciplinary protocols or guidelines for high-risk obstetrical patients at risk for postpartum hemorrhage.

Bao Y, Xu C, Qu X, et al. Risk factors for transfusion in cesarean section deliveries at a tertiary hospital. Transfusion. 2016;56:2062–2068.

Correspondence: Hao Ying at stephenying_2011@163.com

Cryoprecipitate indications and patterns of use in the pediatric intensive care unit

Cryoprecipitate is produced from the cold insoluble fraction of fresh frozen plasma and consists of fibrinogen, factor VIII, von Willebrand factor, factor XIII, and fibronectin. It is transfused to replace fibrinogen levels for bleeding patients and is a second line therapy for von Willebrand disease, hemophilia A, factor XIII deficiency, and uremic bleeding. The authors conducted a study to evaluate the indications for cryoprecipitate and appropriateness of utilization in critically ill children. They retrospectively reviewed electronic medical records for cryoprecipitate ordering and use in a pediatric intensive care unit at a large tertiary care academic center during a 4.5-year period. The records showed that only 44 patients received cryoprecipitate for fibrinogen replacement, and the most common clinical scenarios for administration were recent cardiac surgery (39 percent) and disseminated intravascular coagulation in the setting of sepsis (32 percent). Of interest, cryoprecipitate was often transfused at higher than recommended doses without a known pretransfusion fibrinogen level. The authors also noted that 61 percent of cryoprecipitate transfusions were considered inappropriate according to institutional guidelines. Furthermore, the indications selected for cryoprecipitate transfusions during physician order entry matched the clinical scenario in only 18 percent of patients. The data suggest that there is a lack of standardization and higher than recommended dosing for cryoprecipitate transfusions in critically ill children. The authors concluded that it is important to perform prospective randomized clinical trials to help determine appropriate indications and dosing for cryoprecipitate in pediatric populations. They have updated their institutional guidelines to recommend that cryoprecipitate be used exclusively to replace fibrinogen.

DeSimone RA, Nellis ME, Goel R, et al. Cryoprecipitate indications and patterns of use in the pediatric intensive care unit: inappropriate transfusions and lack of standardization. Transfusion. 2016;56:1960–1964.

Correspondence: Dr. Melissa M. Cushing at mec2013@med.cornell.edun