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• W4307722760 abstract "Central MessageA single transfusion threshold cannot be recommended. Tools to determine Do2 and Vo2 at the level of the microcirculations are urgently needed to facilitate physiology-based transfusion therapy.See Article page XXX. Although transfusions can save lives,1DiNardo J.A. Blood transfusions might be bad for you; that is unless you are bleeding.Anesth Analg. 2013; 116: 1201-1203https://doi.org/10.1213/ane.0b013e3182908e92Crossref PubMed Scopus (0) Google Scholar transfusion of allogenic blood is not without consequences,2Long J.B. Engorn B.M. Hill K.D. Feng L. Chiswell K. Jacobs M.L. et al.Postoperative hematocrit and adverse outcomes in pediatric cardiac surgery patients: a cross-sectional study from the Society of Thoracic Surgeons and Congenital Cardiac Anesthesia Society Database Collaboration.Anesth Analg. 2021; 133: 1077-1088https://doi.org/10.1213/ane.0000000000005416Crossref PubMed Google Scholar especially in pediatric cardiac patients where the high incidence of alloimmunization is not inconsequential.3Cruz-Beltran S. Lane A. Seth S. Miller K. Moore R.H. Sullivan H.C. et al.Antibodies to human leukocyte antigens and their association with blood product exposures in pediatric patients undergoing cardiac transplantation.Pediatr Anesth. 2021; 31: 1065-1073https://doi.org/10.1111/pan.14269Crossref PubMed Scopus (3) Google Scholar Due to a lack of evidence,4Valentine S.L. Bembea M.M. Muszynski J.A. Cholette J. Doctor A. Spinella P.C. et al.Consensus recommendations for RBC transfusion practice in critically ill children from the pediatric critical care transfusion and anemia expertise initiative.Pediatr Crit Care Med. 2018; 19: 884-898https://doi.org/10.1097/pcc.0000000000001613Crossref PubMed Scopus (0) Google Scholar red blood cell (RBC) transfusions are administered based on clinical judgments without evidence that oxygen consumption (Vo2) has become oxygen delivery (Do2)-dependent and potentially limited by hemoglobin concentration. Mubbasheer and colleagues5Ahmed M. Acosta S.I. Hoffman G.M. Tweddell J.S. Ghanayem N.S. Mathematical analysis of hemoglobin target in univentricular parallel circulation.J Thorac Cardiovasc Surg. 2022; (XXX:XXX)Abstract Full Text Full Text PDF Scopus (1) Google Scholar use a modification of the Barnea and colleagues6Barnea O. Austin E.H. Richman B. Santamore W.P. Balancing the circulation: theoretic optimization of pulmonary/systemic flow ratio in hypoplastic left heart syndrome.J Am Coll Cardiol. 1994; 24: 1376-1381https://doi.org/10.1016/0735-1097(94)90123-6Crossref PubMed Scopus (141) Google Scholar mathematical model of single-ventricle physiology and its underlying assumptions to demonstrate that a hemoglobin level of 9 g/dL would lead to severe arterial (arterial oxygen saturation <70%) and venous (venous oxygen saturation <40%) hypoxemia in the presence of a cardiac index of 6 L/m2/min, Vo2 of 150 mL/min/m2, and a Qp/Qs ∼1. They determine that a cardiac index around 9 L/m2/min or a hemoglobin concentration ≥13 g/dL would be needed to maintain optimal levels of Do2 and Vo2. The model is elegant but unfortunately systemic and tissue Do2 is not quite so simple. Blood flow is regulated at 3 places in the circulation: the systemic circulation (cardiac output), the regional circulations (the distribution of blood flow between organs), and the microcirculation (the distribution of blood flow within organs). Although Do2 can systematically be increased by RBC transfusion, this does not guarantee that Do2 is increased at the level of the microcirculation. Using a mathematic model describing the treatment of normovolemic anemia with blood transfusion, Li and colleagues7Li W. Tsai A.G. Intaglietta M. Tartakovsky D.M. A model of anemic tissue perfusion after blood transfusion shows critical role of endothelial response to shear stress stimuli.J Appl Physiol. 2021; 131: 1815-1823https://doi.org/10.1152/japplphysiol.00524.2021Crossref PubMed Scopus (1) Google Scholar found that the influence of RBC transfusion on Do2 varies significantly depending on the ability of the endothelium to respond to increases in wall shear stress induced by blood viscosity. In a microvasculature responsive to wall shear stress, RBC transfusion increases nitric oxide production and induces vasodilation, which results in increased Do2 despite the increase in blood viscosity. In the presence of nonresponsive endothelium, RBC transfusion may lower Do2 due to an unopposed increase in blood viscosity. Furthermore, a minimum viscosity level is necessary to generate the shear stress and the release of nitric oxide and prostacyclin needed to maximize cardiac output.8Martini J. Tsai A.G. Cabrales P. Johnson P.C. Intaglietta M. Increased cardiac output and microvascular blood flow during mild hemoconcentration in hamster window model.Am J Physiol Heart Circ Physiol. 2006; 291: H310-H317https://doi.org/10.1152/ajpheart.01218.2005Crossref PubMed Scopus (26) Google Scholar Similarly, Zimmerman and colleagues9Zimmerman R.A. Tsai A.G. Intaglietta M. Tartakovsky D.M. A mechanistic analysis of possible blood transfusion failure to increase circulatory oxygen delivery in anemic patients.Ann Biomed Eng. 2019; 47: 1094-1105https://doi.org/10.1007/s10439-019-02200-9Crossref PubMed Scopus (6) Google Scholar have suggested that the optimal hematocrit level should be defined as the hematocrit at which increased oxygen-carrying capacity and oxygen-diffusive losses due to reduced blood flow velocity from increased viscosity are balanced such that Do2 is maximized. Chronic cyanosis has been shown to be associated with microcirculatory abnormalities10Cordina R.L. Celermajer D.S. Chronic cyanosis and vascular function: implications for patients with cyanotic congenital heart disease.Cardiol Young. 2010; 20: 242-253https://doi.org/10.1017/s1047951110000466Crossref PubMed Scopus (0) Google Scholar and sublingual microvascular perfusion in some patients with altered microcirculation can be improved following RBC transfusion.11Sakr Y. Chierego M. Piagnerelli M. Verdant C. Dubois M.-J. Koch M. et al.Microvascular response to red blood cell transfusion in patients with severe sepsis.Crit Care Med. 2007; 35: 1639-1644https://doi.org/10.1097/01.ccm.0000269936.73788.32Crossref PubMed Scopus (0) Google Scholar Finally, stored RBCs manifest slower oxygen unloading, which may compromise the efficacy of transfusions (Figure 1).12Rabcuka J. Blonski S. Meli A. Sowemimo-Coker S. Zaremba D. Stepehson D. et al.Metabolic reprogramming under hypoxic storage preserves faster oxygen unloading from stored red blood cells.Blood Adv. 2022; 6: 5415-5428https://doi.org/10.1182/bloodadvances.2022007774Crossref PubMed Scopus (2) Google Scholar Clearly, further studies are needed evaluate the effect of RBC transfusion on Do2 and Vo2 at the level of the microcirculation. Whereas RBC transfusion remains the treatment of choice to treat acute anemia, a single transfusion threshold is still not a viable approach. Alternatives should be explored to treat chronic anemia (eg, iron deficiency anemia).13Corwin H.L. Shander A. Speiss B. Munoz M. Faraoni D. Calcaterra D. et al.Management of perioperative iron deficiency in cardiac surgery: a modified RAND Delphi study.Ann Thorac Surg. 2020; 113: 316-323https://doi.org/10.1016/j.athoracsur.2020.11.031Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Mathematical analysis of hemoglobin target in univentricular parallel circulationThe Journal of Thoracic and Cardiovascular SurgeryPreviewThe hemoglobin threshold for a decision to transfuse red blood cells in univentricular patients with parallel circulation is unclear. A pediatric expertise initiative put forth a “weak recommendation” for avoiding reflexive transfusion beyond a hemoglobin of 9 g/dL. We have created a mathematical model to assess the impact of hemoglobin thresholds in patients with parallel circulation. Full-Text PDF" @default.
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• W4307722760 title "Commentary: Red blood cells transfusion in patients undergoing congenital cardiac surgery: Still far from physiology-based practice" @default.
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