Asian Journal of Transfusion Science
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ORIGINAL ARTICLE  
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Blood component utilization in hospitalized COVID-19 patients: Experience from a dedicated COVID-19 center


1 Department of Transfusion Medicine, AIIMS, New Delhi, India
2 Department of Critical and Intensive Care, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, AIIMS, New Delhi, India
3 Department of Laboratory Medicine, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, AIIMS, New Delhi, India
4 Department of Anaesthesia, Pain Medicine and Critical Care, Jai Prakash Narayan Apex Trauma Center, AIIMS, New Delhi, India

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Date of Submission10-Dec-2021
Date of Decision01-Feb-2022
Date of Acceptance13-Feb-2022
Date of Web Publication12-Dec-2022
 

   Abstract 

BACKGROUND: Blood transfusion services were seriously affected during COVID-19 not only due to limited availability of blood components but also due to gap in the clinical knowledge about the need for transfusion in COVID-19 patients. However, understanding the transfusion needs is essential for inventory management. We analyzed the utilization of blood components in hospitalized COVID-19 patients and recorded the outcome of the patients who were transfused.
MATERIALS AND METHODS: The study included all COVID-19 patients who underwent transfusions over a time period. Patient details included demographics, clinical condition, comorbidities, laboratory parameters, and outcome. Details of transfusion were collected from the blood bank and patient records.
RESULTS: Of 3052 hospitalized COVID-19 patients, 395 (12.9%) were transfused blood components and were included in the study. Comorbidities were identified in 85% of these patients. Red blood cell (RBC) was transfused in 348 (11.4%) with a mean of 2.3 units/patient. Similarly, platelets and fresh frozen plasma were transfused in 3.3% of patients (mean 6.2 units) and 3% (mean 4.9 units), respectively. Transfusion triggers were largely restrictive in nature. Patients with haemato-oncologic conditions required significantly higher numbers of RBCs and random donor platelets. RBCs transfusion were also higher in patients requiring intensive care unit care and ventilatory support. Blood components usage was not affected by severity of COVID-19 disease, comorbidity index, or coagulopathy.
Conclusion: Blood utilization in COVID-19 patients is typically low. Blood components were mainly required by patients with preexisting comorbidities, or those requiring critical care. RBCs were the predominant blood component transfused. Coagulopathy associated with COVID-19 did not necessitate transfusion.

Keywords: Blood transfusion, COVID-19, critical care, severe acute respiratory syndrome-coronavirus-2


How to cite this URL:
Chaurasia R, Aggarwal R, Chopra S, Gupta S, Altaf I, Pandey HC, Patidar GK, Soni KD, Subramanian A, Trikha A. Blood component utilization in hospitalized COVID-19 patients: Experience from a dedicated COVID-19 center. Asian J Transfus Sci [Epub ahead of print] [cited 2023 Jan 28]. Available from: https://www.ajts.org/preprintarticle.asp?id=363220



   Introduction Top


Severe acute respiratory syndrome-coronavirus-2 has spread progressively throughout the world since the first cluster of pneumonia cases that were reported from Wuhan, China, in December 2019.[1] Till date, over 220 million people have been affected by the disease and has resulted in more than 4.5 million deaths worldwide.[2] Majority of the affected individuals are asymptomatic or mildly affected; 15% develop severe disease requiring oxygen support and 5% become critical requiring intensive care admission.[3] Apart from pulmonary manifestations, COVID-19 causes an array of extrapulmonary manifestations, one of which is COVID-19-associated coagulopathy and thrombocytopenia as evidenced by elevated D-dimers, fibrinogen, and a prolongation of the prothrombin time (PT).[4] These alterations are significantly common in patients with severe COVID-19 disease and thus proposed as possible biomarkers for those requiring hospitalization and intensive care unit (ICU) care.

In the view of ongoing pandemic, transfusion management of hospitalized COVID-19 affected individuals poses a significant challenge to the blood transfusion services due to the limited availability of blood and blood components and gap in the clinical knowledge to predict the need for blood transfusions. Although several authors have evaluated the utilization of blood and blood components in COVID-19 patients, clinical and demographic factors associated with transfusion in these patients and the effects of blood component on the clinical condition and outcome of the patients are not well described. Baseline knowledge about the underlying factors for transfusion and the effects of transfusion is necessary for clinical practice and for planning inventory and policymaking. To address this, we retrospectively analyzed the utilization of blood components in patients who were confirmed positive for COVID-19 and were hospitalized. We also analyzed demographic and clinical factors in these patients, evaluated the triggers for transfusion and recorded the outcome in transfused patient population.


   Materials and Methods Top


This study was done in 300 bedded dedicated COVID center (inclusive of more than 70 ICU beds), All India Institute of Medical Sciences, New Delhi. The study was approved by the Institutional Ethics Committee (IEC-878/January 03, 2020) and conducted over a 7-month period, starting from April 2020 to October 2020. All confirmed COVID-19 patients above the age of 18 years who were transfused blood components were included in the study for data analysis. Patients who required transfusion for emergency surgery for trauma or obstetric reasons were excluded from the analysis.

Patient details were collected from computerized patient record system and patient files and included demographics such as age, gender, clinical diagnosis, severity of COVID-19 (mild/moderate/severe) as per the criteria laid by the Indian Council of Medical Research, underlying comorbidity (Charlson Comorbidity Index), date and time of admission, vitals (pulse, blood pressure, temperature, and SpO2), baseline laboratory values for hemoglobin (Hb), platelet count, PT, and activated partial thromboplastin time (aPTT). During hospitalization, changes in the oxygen requirement were also assessed. Patient outcome was primarily assessed as all-cause mortality, days of ICU stay, number of ventilator days, and days of hospital stay.

Details of transfusion were collected from the blood bank records which included the timing, number, and the type of the blood components, including red blood cells (RBC), random donor platelets (RDP), fresh frozen plasma (FFP), and cryoprecipitate that were transfused to the patients during the hospital stay.

Data collected were entered and analyzed using the SPSS version 20.0 (Armonk, NY, USA: IBM Corporation). Descriptive analysis was performed for the patient demographics, clinical and laboratory variables, and utilization of the blood components. Pretransfusion laboratory values were evaluated as trigger for transfusions. The survivors were compared with nonsurvivors in terms of baseline characteristics and transfusion components.


   Results Top


Demographic, epidemiological parameters, and clinical characteristics

A total of 3052 confirmed cases of COVID-19 were admitted during the study period, of which 463 were transfused. Of these, 42 patients below 18 years of age and 26 patients requiring emergency surgery for trauma and obstetric cases were excluded, resulting in the inclusion of a total of 395 (12.9%) patients for data analysis [Figure 1]. The median age of the patients was 44 years (interquartile range [IQR] 30–56 years) and there were 241 (61%) male patients. Clinical characteristics of study patients are shown in [Table 1]. Of 395 patients, 336 (85.1%) patients were identified with underlying comorbidities, and this included 105 (26.6%) patients who had more than one comorbidity. The frequency distribution of the underlying comorbid conditions is illustrated in [Figure 2].
Table 1: Demographic, epidemiological parameters, and clinical characteristics of study patients (n=395)

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Figure 1: Flow chart for patients included in the study

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Figure 2: Distribution of comorbid condition in transfused COVID-19 patients (some patients had multiple comorbidities)

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The severity of COVID at admission was assessed. Almost half of the patients (52.2%) had mild COVID, 30% had moderate, and 17.7% had severe COVID at admission. However, some patients with mild and moderate disease progressed to severe disease. Mild-to-moderate cases were managed in the wards and moderate cases with risk factors and severe cases were managed in the ICU. Of all patients, 171 (43.3%) required ICU care. The treatment was instituted according to the institutional protocol. The overall median length of hospital stay was 11 (IQR 9–18) days in all patients. The median duration of ICU stay was 8 (IQR 5–15) days among 171 patients who required ICU care, whereas the median duration for ventilator support was observed to be 5 days (IQR 3–10) in 148 patients requiring invasive ventilation.

The overall mortality was 37.7% (149) in our cohort with septic shock as the major cause in 41.6% (62), followed by Acute respiratory distress syndrome (ARDS) in 30.2% (45), hemorrhagic shock in 3.3% (5), and other causes in 24% (37) patients.

Transfusion details

The baseline coagulopathy as denoted by deranged international normalized ratio (INR) (i.e., INR more than 1.5 times normal) and prolonged PT (more than 1.5 times normal) was observed in around 10% of the patients transfused. During the study period, a total of 1884 blood components were transfused in 395 patients (mean 4.8 units/patient). This included 791 RBCs in 348 patients (mean 2.3 units/patient), 642 RDP in 102 patients (mean 6.3 units/patient), and 451 FFP were transfused to 92 patients (mean 4.9 units/patient). Pretransfusion laboratory variables for transfusions of different blood components are shown in [Table 2]. For some patient's pretransfusion laboratory values were not available, indicating that transfusions were administered based upon clinical status or arterial blood gas values.
Table 2: Trigger values for transfusion episodes

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When compared to other comorbidities, patients with an underlying hematologic condition or haemato-oncologic condition required significantly increased number of RBCs (3.6 ± 3.3 vs. 2.1 ± 1.5; P = 0.005) and RDPs (9.5 ± 7.9 vs. 4.6 ± 4.2; P = 0.005), unlike for plasma components (4.4 ± 1.8 vs. 4.9 ± 2.8; P = 0.441). Similarly, the mean RBCs transfusion was higher in patients who required ICU care (2.6 ± 2.3 vs. 2.0 ± 1.6 in non-ICU patients; p-0.004) and those who required ventilatory support (2.6 ± 2.1 vs. 2.1 ± 1.8; p-0.019). No other significant differences in blood components usage were noted among different patient groups based on the severity of the COVID-19 disease or Charlson Comorbidity Index. The survivors were compared with nonsurvivors in terms of baseline characteristics and transfusion components [Table 3]. The median age, Charlson Comorbidity Index, severity of COVID was higher in nonsurvivors as compared to survivors. Pretransfusion Hb and platelets were significantly lower in nonsurvivors, and higher number of RBCs were transfused among them, however, there were no differences in pretransfusion coagulation parameters and requirement of platelets and FFP.
Table 3: Difference between survivors and nonsurvivors among the transfused cohort (n=395)

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   Discussion Top


Among the ongoing pandemic, decreased number of blood donations coupled with inadequate knowledge about the blood transfusion requirements and lack of demographic profile of the transfused COVID-19 affected patients led to difficulties in managing inventory for blood and blood components.[5],[6] Initial studies assessing the blood utilization during the pandemic have shown variable results, with transfusion rates ranging from 1.6% to 13.4% in COVID-19 patients.[7],[8],[9],[10],[11] Most of these studies have not clearly identified the underlying clinical condition of the patients which necessitated transfusion of the blood and blood components. In our study, the transfusion rate was nearly 13%. Majority of the patients transfused in our study were males and middle-aged, unlike the other studies where elderly patients required more transfusion. Increased number of transfusions among the middle-aged population in our study group can be attributed to differences in the epidemiological profile of the COVID-19 positive populations in our country.[12]

In our study, over 85% of the transfused patients had preexisting comorbidities such as chronic kidney diseases, liver disorders, pulmonary disorders, cardiovascular conditions, cerebrovascular conditions, diabetes, hypertension, hematologic, and other malignant conditions. As a result, the presence of such risk factors often necessitated early admissions in some instances.[13] The most common comorbidity among the transfused population was chronic kidney disease (23%), followed by 19% of patients with malignancies (both hematologic and nonhematologic), chronic liver disease (19%), hypertension (19%), and diabetes (17%). Unlike our study, Dalmazzo et al. have reported hypertension and diabetes as the major comorbidities among the transfused population.[8]

RBCs were the predominant blood component transfused and was transfused in 11.4% of patients with an average of 2.3 RBC units per patient. The overall RBC utilization per patient in our study was lower, when compared to utilization rates reported in other studies. Decreased utilization of RBC can be due to adoption of restrictive transfusion strategy and policy of issuing single RBC unit during the pandemic, to reduce wastage as no returning back of blood component was allowed from COVID-19 area in the hospital. Available pretransfusion Hb values were also much lower when compared to other studies.[8] Mean RBC utilization was significantly higher among patients with hemato-oncologic disorders (mean of 3.6 vs. 2.1; P = 0.005) and among those requiring ICU care and ventilator support. In our study, 43.3% of the patients required ICU care, with a median duration of ICU stay of 8 days. The odds of RBC transfusion have been shown to increase with the length of ICU stay. The finding in our study was concordant to other group of patients admitted in ICU, where nearly 40% of ICU patients become anemic (Hb <90 g/L) during their ICU stay;[14] thus, explaining the correlation of RBC transfusion with the length of ICU stay. We also observed that the number of RBC units transfused was associated with an increase in the oxygen requirement during the hospital stay and patient outcome. However, its causal association was not investigated due to lack of clinical data among the non-transfused cohort.

Mild thrombocytopenia has been reported in 5%–21% of COVID-19 patients in various studies. Decreased platelet production, autoimmune destruction of platelets, or increased platelet consumption are the common reasons for thrombocytopenia in COVID-19. Degree of thrombocytopenia is usually mild in most of the patients, with a reported platelet nadir of 185 × 103/L. As a result, platelet transfusion is often not required.[7] Approximately 2%–3% of the hospitalized patients have been reported to require platelets transfusion.[7],[8],[10],[11] The presence of hematological and other malignant conditions in these patients may complicate the situation, resulting in the transfusion of platelet concentrates.[15] In our study, platelet transfusions were required by more than 3% of the total (3052) hospitalized patients with a mean of 6.2 units of RDP per patient and median pretransfusion platelet counts were 35 × 103/L. Mean RDP utilization was also found significantly higher among patients with hemato-oncologic disorders (mean of 9.5 vs. 4.8; P = 0.003) of all the cases. RDP transfusions also correlated with the days of ICU stay and the number of ventilator days, which is a common finding for other critically ill patients requiring ICU care.[16]

Coagulopathy in COVID-19 is characterized by an increase in fibrinogen and D-dimer levels and mild prolongation of PT/aPTT.[4],[17] The severity of coagulopathy is also associated with the severity of the disease and rarely progresses to meet the criteria for disseminated intravascular coagulation (DIC). As per the initial reports of coagulopathy, there was an increased apprehension for an increased risk of bleeding and thus higher requirement of plasma components among the blood transfusion services. On the contrary, COVID-19 infection infrequently leads to bleeding despite abnormal coagulation parameters and patients require blood components occasionally. It has also been pointed out that coagulopathy in COVID-19 may be complicated by liver dysfunction which may increase the risk of bleeding.[18] In our study, 3% of total (3052) patients required FFP transfusion, and cryoprecipitate was not utilized for any of the patients. Other studies have also reported that plasma and/or cryoprecipitate was required only in 1%–2% of patients. We did not find any correlation of FFP transfusion with pretransfusion PT/aPTT values, as data were missing for most of the transfusion episodes. No correlation with FFP transfusion and liver disorders was noted.

Our study has some limitations, this includes the retrospective nature of the study itself, missing laboratory data for underlying coagulopathy, and the inability to compare the outcome of the patients who were transfused with the nontransfused cohort.


   Conclusion Top


Blood utilization in COVID-19 patients is typically low and does not affect the blood inventory levels significantly, despite the decreased number of blood donations. Blood and blood component therapy are mainly required by patients with preexisting comorbidities or those requiring critical care. RBCs were the predominant blood component transfused. Coagulopathy associated with COVID-19 did not necessitate blood transfusion. Studies that include the clinical status of the patients along with the interventions performed will help us in guiding transfusion for these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.  Back to cited text no. 1
    
2.
WHO. WHO Coronavirus (COVID-19) Dashboard. World Health Organization; 2021. Available from: https://covid19.who.int/. [Last accessed on 2021 Sep 07; Lastupdated on 2021 Sep 06].  Back to cited text no. 2
    
3.
World Health Organization. (2020). Coronavirus disease 2019 (COVID-19): situation report, 46. World Health Organization. https://apps.who.int/iris/handle/10665/331443. [Last accessed on 2022 Mar 06].  Back to cited text no. 3
    
4.
Levi M, Thachil J, Iba T, Levy JH. Coagulation abnormalities and thrombosis in patients with COVID-19. Lancet Haematol 2020;7:e438-40.  Back to cited text no. 4
    
5.
Stanworth SJ, New HV, Apelseth TO, Brunskill S, Cardigan R, Doree C, et al. Effects of the COVID-19 pandemic on supply and use of blood for transfusion. Lancet Haematol 2020;7:e756-64.  Back to cited text no. 5
    
6.
Pandey HC, Coshic P, Chippy CS, Arcot PJ, Kumar K. Blood supply management in times of SARS-CoV-2 pandemic – Challenges, strategies adopted, and the lessons learned from the experience of a hospital-based blood centre. Vox Sang 2021;116:497-503.  Back to cited text no. 6
    
7.
Barriteau CM, Bochey P, Lindholm PF, Hartman K, Sumugod R, Ramsey G. Blood transfusion utilization in hospitalized COVID-19 patients. Transfusion 2020;60:1919-23.  Back to cited text no. 7
    
8.
Dalmazzo LF, de Almendra Freitas AF, Alves BE, Cardoso DK, de Carvalho EF, Akil F, et al. Transfusion profile, clinical characteristics, comorbidities and outcomes of 3014 hospitalized patients diagnosed with COVID-19 in Brazil. Vox Sang 2021;116:983-9.  Back to cited text no. 8
    
9.
Fan BE, Ong KH, Chan SS, Young BE, Chong VC, Chen SP, et al. Blood and blood product use during COVID-19 infection. Am J Hematol 2020;95:E158-60.  Back to cited text no. 9
    
10.
DeSimone RA, Costa VA, Kane K, Sepulveda JL, Ellsworth GB, Gulick RM, et al. Blood component utilization in COVID-19 patients in New York City: Transfusions do not follow the curve. Transfusion 2021;61:692-8.  Back to cited text no. 10
    
11.
Das SS, Biswas RN. Blood component therapy in coronavirus disease-2019 patients hospitalized in a tertiary care center in Eastern India. Glob J Transfus Med 2021;6:43.  Back to cited text no. 11
    
12.
Chanda A. COVID-19 in India: Transmission dynamics, epidemiological characteristics, testing, recovery and effect of weather. Epidemiol Infect 2020;148:e182.  Back to cited text no. 12
    
13.
Girmenia C, Gentile G, Micozzi A, Petrucci L, Malaspina F, Di Prima A, et al. COVID-19 in patients with hematologic disorders undergoing therapy: Perspective of a large referral hematology center in Rome. Acta Haematol 2020;143:574-82.  Back to cited text no. 13
    
14.
Akbaş T. Long length of stay in the ICU associates with a high erythrocyte transfusion rate in critically ill patients. J Int Med Res 2019;47:1948-57.  Back to cited text no. 14
    
15.
Senapati J, Aggarwal M, Louis L, Mirza SA, Kumar P, Dhawan R, et al. Transfusion practices during the COVID-19 pandemic: An experience from a hematology daycare in India. Transfus Apher Sci 2021;60:103025.  Back to cited text no. 15
    
16.
McIntyre L, Tinmouth AT, Fergusson DA. Blood component transfusion in critically ill patients. Curr Opin Crit Care 2013;19:326-33.  Back to cited text no. 16
    
17.
Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost 2020;18:844-7.  Back to cited text no. 17
    
18.
Shalimar, Vaishnav M, Elhence A, Kumar R, Mohta S, Palle C, et al. Outcome of conservative therapy in coronavirus disease-2019 patients presenting with gastrointestinal bleeding. J Clin Exp Hepatol 2021;11:327-33.  Back to cited text no. 18
    

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Correspondence Address:
Richa Aggarwal,
Department of Critical and Intensive Care, Jai Prakash Narayan Apex Trauma Center, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajts.ajts_179_21



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