Transfusion medicine reviews
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Transfusion-related acute lung injury (TRALI) is a major cause of transfusion-related morbidity and mortality. Although the pathogenesis of TRALI is incompletely understood, substantial data from hemovigilance systems, large case series, clinical trials, and animal models have identified antileukocyte antibodies as a major precipitant and have contributed to the development of concrete interventions to reduce the risk of TRALI. This review presents the clinical data supporting specific donor management strategies to reduce TRALI risk and their observed clinical efficacy. Novel strategies that use the donor health questionnaire combined with testing are discussed, and important challenges that remain going forward are explored.
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Large scale red blood cell (RBC) antigen genotyping of donors is currently well developed. There is scarce information, however, to select patients who might benefit from preemptive extended RBC antigen-matched transfusions. Female sex has been proposed as a risk factor for RBC alloimmunization after transfusion. ⋯ This is likely explained by more exposure to immunizing events through pregnancy and/or transfusions in females with sickle cell disease. The results support the current policy implemented in many countries for Rhesus/Kell matching in patients with a hemoglobinopathy irrespective of sex. Thus, based solely on sex difference, the results do not justify recommending additional matching for women, besides preemptive K and c antigen matching for women during the (pre-) fertile age, as already applied in many European countries for the prevention of fetal morbidity.
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Randomized Controlled Trial
The PRECISE RCT: evolution of an early septic shock fluid resuscitation trial.
Severe sepsis and septic shock are the most common reasons for admission to an intensive care unit; and the risk of death is substantial, estimated at approximately 40%. Evidence suggests that early resuscitation strategies that include the use of resuscitation fluids, antibiotics, blood, and inotropes reduce death. Although fluid resuscitation is an immediate life-saving intervention, a fundamental question that remains unanswered is whether the type of resuscitation fluid impacts survival when it is initiated very early in the course of septic shock. ⋯ In contrast, a subgroup analysis from a randomized controlled trial suggests that 4% albumin fluid may reduce death from severe sepsis; however, these findings require confirmation in a large randomized trial. Our team is planning a pragmatic early septic shock fluid resuscitation trial that will compare the effectiveness of 5% albumin vs normal saline on 90-day mortality (PRECISE). In this article, we summarize the scientific rationale and inherent challenges associated with the conduct of PRECISE, the background work and planning elements that have been undertaken, and the PRECISE RCT protocol with rationale and justifications provided for the chosen population, the interventions, and the outcome measures.