key: cord-309739-3smgv1ma authors: Doyle, Andrew J; Danaee, Anicee; I Furtado, Charlene; Miller, Scott; Maggs, Tim; Robinson, Susan E; Retter, Andrew title: Blood Component Use in Critical Care in Patients with COVID‐19 Infection: A Single Centre Experience date: 2020-07-08 journal: Br J Haematol DOI: 10.1111/bjh.17007 sha: doc_id: 309739 cord_uid: 3smgv1ma There has been a significant surge in admissions to critical care during the COVID‐19 pandemic. At present, the demands on blood components have not been described. We reviewed their use during the first 6 weeks of the outbreak from 3(rd) March 2020 in a tertiary‐level critical care department providing veno‐venous extracorporeal membrane oxygenation (vv‐ECMO). 265 patients were reviewed ‐ 235 not requiring ECMO and 30 requiring vv‐ECMO. In total, 50 patients required blood components during their critical care admission. Red cell concentrates were the most frequently transfused component in COVID‐19 infected patients with higher rates of use during vv‐ECMO. The use of fresh frozen plasma, cryoprecipitate and platelet transfusions was low in a period prior to the use of convalescent plasma. Since the outbreak of the COVID-19 pandemic, there has been a surge in admissions to intensive care departments. At present it has not been described whether there is an increased blood component requirement in patients with COVID-19 infection. Coagulopathy is present in 20-55% of cases and is related to disease severity and worse survival outcomes (Lee et al, 2020) . Prothrombotic markers such as fibrinogen and d-dimer are increased with COVID-19 infection with an absence of significant rates of disseminated intravascular coagulation (DIC) but higher incidence of thrombosis (Klok et al, 2020; Yin et al, 2020) . Restrictive transfusion practice of red blood cells in critical care and extracorporeal membrane oxygenation (ECMO) has similar survival outcomes to liberal transfusion practice (Herbert et al, 1999; Klein, 2013; Doyle et al, 2020) . There is concern that COVID-19 infection disproportionately affects the Black, Asian and Minority Ethnic (BAME) population (Cato et al, 2020) . Blood group disparity between donors and recipients in the United Kingdom, particularly from different ethnic groups affected by COVID-19, may therefore be a potential issue (Lattimore et al, 2015) . Our centre provides extensive regional critical care facilities including venovenous extracorporeal membrane oxygenation (vv-ECMO). Patients requiring ECMO have increased use of blood components particularly if they bleed (Doyle et al, 2020; Agerstrand, 2020) . In anticipation of increased hospitalisations and a decline in blood donation due to social distancing measures, elective major surgery has largely been postponed in keeping with nationwide policy. We aim to evaluate the current blood product usage, the demographics of those requiring blood components, and their requirements and indications. A prospective database of patients with COVID-19 infection admitted to critical care was reviewed to identify appropriate patients. Dates of inclusion were from 3 rd March 2020 to 14 th April 2020 inclusive. Blood traceability is maintained on WinPath Laboratory Integrated Management System (Chertsey, United Kingdom) with transfused blood components identified from this during critical care admissions. Blood components included were red cell concentrate (RCC), platelets, fresh frozen plasma (FFP) and cryoprecipitate. Blood groups were identified from the iSOFT Clinical Manager Electronic Patient Records software (Sydney, Australia). Data were screened on 21st April 2020. Indications for blood component This article is protected by copyright. All rights reserved transfusion were evaluated against the National Blood Transfusion Committee (NBTC) Indication Code for Transfusion (June 2016) (NBTC, 2016). As transfusion during ECMO is not included in the NBTC policy, a RCC transfusion trigger of haemoglobin <80g/L is adopted locally. All patients received weight-and renal function-dose adjusted chemical thromboprophylaxis unless actively bleeding or required therapeutic anticoagulation. 265 patients were identified for review in the above time period. Thirty patients required the use of vv-ECMO, and 235 other patients were admitted to critical care but did not require ECMO support. Table III . RCC was the predominant blood component used. There was low use in platelets, FFP and cryoprecipitate in both ECMO and non-ECMO patients. There were three episodes of non-intracranial major haemorrhages (6% of transfused patients and 1% of all patients). There was a mean use of 11 units RCC, 4 FFP and 0.3 cryoprecipitate in these patients during the bleeding episodes with no platelets transfused. Two episodes of exchange transfusion occurred for patients with sickle cell disease (each requiring 8 RCC units). The highest utilisation of platelets was in a patient with acute myeloblastic leukaemia who remained severely thrombocytopenic with sepsis following induction chemotherapy (9 units used). Despite the increased demands of healthcare resources at the time of the COVID-19 pandemic, it appears that the infection itself does not cause a significant increase in blood component use in comparison to previous data from critical care (Chohan et al, 2003) . There was a lack of other blood requirements or This article is protected by copyright. All rights reserved presence of allo-antibodies in this cohort. There was a predominance of BAME patients being treated in comparison to the donor population of the United Kingdom, reflected in a higher than expected number of patients with blood group B. There were low rates of major haemorrhage over the period, confined to patients requiring ECMO. As described previously, the use of ECMO showed higher but similar levels of RCC usage, previously estimated at 0.44-0.66 units per day at our Centre (Doyle et al, 2020) . This is in comparison 0.46 units per day in patients not requiring ECMO in critical care prior to the COVID-19 outbreak (Chohan et al, 2003) . The predominant blood component used was RCC in both patients requiring ECMO and those not requiring ECMO. The most common indications for their transfusion were for maintenance of haemoglobin targets (NBTC Codes R2 and R3) comprising of 64.6% and 73.8% respectively (NBTC, 2016) . Preliminary data from China suggests that anaemia is more prevalent in those with COVID-19 requiring critical care with a progressive fall in haemoglobin over admission (Sun et al, 2020) . Although the mechanism of this remains unclear at present, iron dysregulation due to inflammation may be a potential cause. Alternative options to red cell transfusion to optimise patient blood management can be considered, such as intravenous iron and recombinant erythropoietin, but their roles in critical care are not well established (Baron et al, 2020; IRONMAN investigators et al, 2016) . Concern of the increased thrombotic rates and inflammatory states in COVID-19 infection in this setting may preclude their widespread use (Lee et al, 2020; Klok et al, 2020; Yin et al, 2020; Panigada et al, 2020) . The use of platelet, FFP and cryoprecipitate transfusions remains low with COVID-19 infection in those who have not had episodes of major haemorrhage. Elevated levels of fibrinogen, factor VIII and platelets are demonstrated in critical illness in COVID-19 infection suggestive of why transfusion triggers for these components were not met in this patient cohort (Lee et al, 2020; Panigada et al, 2020) . Given the prothrombotic tendency of COVID-19 infection, unnecessary transfusion of plasma components should be avoided in the absence of bleeding. A significant decline in blood donation has been shown in China although initial concerns of this in the UK have been offset by a fall in transfusion rates (Wang et al, 2020; NHS Blood and Transplant, 2020) . Our results suggest that blood component usage as a result of COVID-19 infection remains low with a higher usage in ECMO. Optimisation of patient blood management in the critical care setting is one consideration to assist with potential shortages of blood component provision in the next few months. 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All rights reservedWe would like to acknowledge the dedication of the Critical Care Department at Guy's and St Thomas' NHS Foundation Trust during this period.