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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 1  |  Page : 43-48

Blood component therapy in coronavirus disease-2019 patients hospitalized in a tertiary care center in eastern India


Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, West Bengal, India

Date of Submission11-Sep-2020
Date of Decision06-Oct-2020
Date of Acceptance18-Mar-2021
Date of Web Publication29-May-2021

Correspondence Address:
Dr. Sudipta Sekhar Das
Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_95_20

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  Abstract 


Background and Objectives: Most patients with coronavirus disease-2019 (COVID-19) do not need blood transfusion, and only a subset of critically ill patients requires transfusion. Here, we describe the pattern of blood usage in COVID-19 patients in our hospital with regard to indications, clinical and laboratory evaluations, and blood and blood component transfusions. Methods: This is a retrospective study that included 34 hospitalized transfused patients admitted with clinical features and diagnosis of COVID-19. Demographic, clinical, laboratory, and blood transfusion details were obtained from patient files and blood bank software. Statistical analysis was done using the IBM SPSS statistical package. Results: Among the 419 hospitalized COVID-19 patients, 34 (8.1%) received blood transfusion. Levels of D-dimer, serum ferritin, and interleukin-6 as high as 8545 ng/mL, 8486 ng/mL, and 256 pg/mL, respectively, were observed in few patients. Comorbidity was demonstrated in 91.2% of transfused patients. A total of 6 (17.6%) patients succumbed to disease. Packed red blood cell was the main blood component transfused to COVID-19 patients followed by platelet (PLT) and plasma products. A rise in trend in blood utilization was demonstrated from March to June 2020 with a dip in July 2020. Compared to other months, more patients required PLT concentrates in June 2020. Conclusion: Blood utilization in COVID-19 patients is usually low and does not affect the blood inventory significantly. Most transfused patients have been critically ill, and the trend in blood utilization in COVID-19 patients may be difficult to ascertain.

Keywords: Anemia, blood component therapy, blood transfusion, coronavirus disease-2019, pandemic


How to cite this article:
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;6:43-8

How to cite this URL:
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 [serial online] 2021 [cited 2021 Dec 7];6:43-8. Available from: https://www.gjtmonline.com/text.asp?2021/6/1/43/317179




  Introduction Top


The novel coronavirus disease-2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a contagious respiratory disease that has affected the entire globe and caused significant disruption in all aspects of human life. Till date, there is no proven effective therapy for COVID-19, and a number of treatment options are on clinical trial.[1] There were observations from previous authors that most patients with COVID-19 do not need blood transfusion, and only a subset of critically ill patients requires transfusion.[1],[2] While most transfused patients required packed red blood cell (PRBC) for anemia, other blood components such as plasma, platelet (PLT) concentrate, and cryoprecipitate were least transfused.[2],[3],[4] Published data reported normal or mildly decreased hemoglobin and PLT values in COVID-19 patients.[5] Coagulation disturbances have been observed in COVID-19 patients with elevated D-dimer and fibrinogen, and high incidences of thrombotic complications have been reported from intensive care units (ICUs).[6],[7] Authors also recommended nonutilization of blood components such as plasma and cryoprecipitate to treat isolated coagulation abnormalities in COVID-19 patients without evidence of bleeding.[8] SARS-CoV-2 infection has been reported to cause increased PLT destruction, increased PLT consumption, and decreased PLT production through increased levels of autoantibodies, immune complexes, and cytokine storm.[9] Thrombocytopenia if does occur is considered as a poor prognostic marker.[10] Authors also documented PLT transfusion in COVID-19 patients to mitigate preprocedural risks of bleeding. Interestingly, very recently, a few cases of simultaneous onset of SARS-CoV-2 infection and autoimmune hemolytic anemia have been described.[11] A positive direct antiglobulin test (DAT) was found in 52 of 113 (46%) COVID-19 patients by Berzuini et al., and authors suggested underlying mechanisms that cause modifications of erythrocyte surface during the course of the disease.

Aims and objectives

In the present study, we described the pattern of blood usage in COVID-19 patients with regard to indications, clinical and laboratory evaluations, and blood and blood component transfusions.


  Materials and Methods Top


This is a retrospective observational study performed from March 18, 2020, to July 31, 2020, in our 750-bedded tertiary care hospital.

Ethics

This study was conducted after obtaining approval from the institute ethics committee.

With increase in COVID-19 infection in the locality, the hospital designated a separate building as COVID block. Our COVID unit started with 20 dedicated COVID beds in March 2020 and it reached 155 in July 2020 that included satellite/quarantine beds, general COVID beds, and 12 intensive and high-dependency care beds. The study included 34 transfused patients out of the 419 hospitalized patients admitted with clinical features and diagnosis of COVID-19. Details of the patients that included demographic, clinical, laboratory, and blood transfusion details were obtained from patient files, hospital information system (HIS), and blood center software.

The blood center which is an integrated part of the hospital has all modern facilities to support the sick patients requiring blood and blood component transfusion. All whole blood collected from healthy blood donors were separated into blood components that included PRBC, plasma, random donor PLTs (RDPs), and cryoprecipitate (Cryo). In addition, the blood center has the facility of collecting single donor PLTs (SDPs) using latest apheresis machines. For all patients requiring blood component transfusion, complete blood requisition with appropriate blood samples for pretransfusion testing was received in the blood center. After mandatory testing, compatible blood component units were reserved for patients for subsequent transfusion. As per our national guidelines, the details of testing and blood issue were documented accordingly.[12] To maintain laboratory safety in the COVID-19 pandemic, we implemented the following methods in the blood center.

  1. Virtual instead of physical blood requisition was obtained through HIS or electronic media from the COVID block
  2. All blood samples collected for COVID patients were transported to blood center in tough polycarbonate box with locked lids
  3. Use of dedicated, close lid, tabletop sample centrifuge machine to minimize the staff–sample aerosol contact
  4. Pretransfusion test was performed using fully automated immunohematology equipment (Ortho AutoVue Innova, Ortho Clinical Diagnostics, New Jersey, USA) to reduce staff–blood sample exposure
  5. Use of disinfection equipment in the laboratory
  6. Ensuring continuous and adequate supply of personal protective equipment to laboratory staff.


Statistical analysis

Statistical analysis was done using the SPSS statistical package (IBM, Armonk, New York, USA). Results were calculated as mean ± standard deviation or expressed as percentage (%). Range of values was calculated wherever applicable. Line graphs were plotted representing variables such as time series (X-axis) and number of patients/blood components (Y-axis) to determine the relationship between these two sets of variables.


  Results Top


Ours being a tertiary care hospital with dedicated COVID beds, we observed blood utilization in COVID-19 patients. Among the 419 hospitalized COVID-19 patients, during the study period, 34 (8.1%) received blood and blood component transfusion. [Table 1] describes the demographic, laboratory, and clinical parameters of the transfused COVID-19 patients. The median age of the transfused patients was 58 years, with a male preponderance (M:F = 3.8:1). The mean hematological values such as hemoglobin (Hb), white blood cell, and PLT count were observed to be 8.9 g/dL, 10.4 × 109/L, and 143.4 × 109/L, respectively. Among the transfused patients, 4 (11.8%) were eventually found to be positive for DAT in the pretransfusion testing. A mean high neutrophil-to-lymphocyte ratio (NLR) of 15.3 was observed among the patients. While the mean levels of D-dimer, fibrinogen, and INR were calculated to be 4394.7 ng/mL, 269.4 mg/dL, and 1.7, respectively, the mean values of serum ferritin, interleukin (IL)-6, C-reactive protein (CRP), and serum creatinine in the COVID-19–transfused patients were 2170.8 ng/mL, 120.8 pg/mL, 10.9 mg/dL, and 2.1 mg/dL, respectively. Levels of D-dimer, serum ferritin, and IL-6 as high as 8545 ng/mL, 8486 ng/mL, and 256 pg/mL, respectively, were also observed in few patients. Single or multiple comorbidity/ies were demonstrated in 91.2% transfused patients. While 30 (88.2%) patients were admitted in high-dependency unit (HDU) or ICU and 19 (55.9%) needed ventilator support, 6 (17.6%) patients succumbed to the disease. The mean length of stay (LOS) was observed to be 19.2 days (7–38 days).
Table 1: Demographic, laboratory, and clinical parameters of transfused COVID-19 patients (n=34)

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PRBC was the main blood component transfused to the COVID-19 patients followed by PLT concentrates and plasma products [Table 2]. A total of 234 blood components were transfused to 34 patients. Among all blood and blood component units utilized in the hospital during the study period, 5.8% units was received by the COVID-19 patients. Again, among all hospitalized patients who received blood transfusion during the study period, 1.6% of transfused patients were suffering from COVID-19.
Table 2: Details of blood component transfusion in COVID-19 patients

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We observed a rise in trend in utilization of PRBC and RDP from the month of March 2020 to latter half of June 2020 with a dip in July 2020, but the usage of plasma and Cryo had vacillating trends [Figure 1]. [Figure 2] describes the trends in the number of COVID-19 patients receiving blood components over time. A total of 12 patients received PRBC and plasma in May 2020 as compared to 8 in July 2020. Compared to other months, more patients required PLT concentrates in the month of June 2020.
Figure 1: Trends in blood component utilization in coronavirus disease-2019 patients

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Figure 2: Trends in number of transfused coronavirus disease-2019 patients

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  Discussion Top


A study on blood utilization in COVID-19 patients is scarce in the literature. Global data reported variable requirement of blood transfusion in COVID-19 patients.[3],[4],[5],[13] Fan et al. in a case series observed that only 0.36% of non-ICU and 36.8% of ICU COVID-19 patients required PRBC transfusion with lesser requirements for plasma and PLTs.[2] We observed that 8.1% of the hospitalized COVID-19 patients required blood components with 5.7% and 2.6% receiving PRBC and PLT transfusions, respectively. Like Barriteau et al., we observed that ICU COVID-19 patients had higher rates of blood component transfusion (88.2%) compared to their counterparts admitted in the COVID wards. These transfusions included components such as red cells, PLTs, fresh frozen plasma, and Cryo. Owing to low blood and blood component utilization in COVID-19 patients, the impact of pandemic and low blood inventory did not affect their transfusion.

Like Fan et al., we demonstrated that most transfused COVID-19 patients were males and elderly. Authors in the recent past investigated that clinical features and prognosis of COVID-19 vary among patients of different ages, and patients aged ≥60 years showed heavier clinical manifestations, greater severity, and longer disease courses compared to younger patients.[14],[15]

While the mean Hb value in transfused patients was found to be 8.9 g/dL, mean Hb in patients receiving only PRBC (5.7%) was 7.3 g/dL. All COVID-19 patients in the present study were transfused with leukodepleted PRBC units with none revealing any adverse reaction. A total of 24 patients required 84 units of PRBC with a mean 3.5 units PRBC usage per patient. Considering the total PRBC units issued to all hospitalized in-patient during the study period, 4% usage was demonstrated in COVID-19 patients. A total of 4 (11.8%) patients who needed blood transfusion showed positive DAT result (2 +–4 + reactivity) in the pretransfusion testing with only IgG as the offending autoantibody. DAT positivity in COVID-19 patients was also reported before, and the possibility of a drug effect could not be ruled out.[3],[16] In the present study, despite taking detailed drug history, we observed no relevant drugs to be associated with DAT positivity.

A total of 11 patients who demonstrated low PLT count of ≤33 × 109/L needed PLT concentrate including SDP. Pooled analysis by Lippi et al. revealed that PLT count was significantly lower in patients with more severe COVID-19 and even lower PLT count was associated with mortality. We demonstrated a high (15.3 ± 3.4) NLR in the transfused patients, and it is said to be associated with increased mortality, acute respiratory distress syndrome, need for ICU care, and severe COVID-19.[17]

A previous observational cohort study concluded that the severity of coagulopathy was associated with severity of COVID-19.[18],[19],[20],[21] Kander added that the features of COVID-19–associated coagulopathy were found unique with very high levels of D-dimer and moderately decreased PLT counts.[19] While the mean INR and D-dimer in our transfused patient were 1.7 and 4394.7 ng/mL, respectively, we also observed even higher INR (≥4.3) and D-dimer (≥5436.7 ng/mL) in patients receiving plasma and/or Cryo. Coagulopathy was reported, and D-dimer elevations were seen in 3.75%–68% of the COVID-19 patients.[20],[21] Tang et al. reported that patients who did not survive their illness presented with higher D-dimer levels, fibrin (ogen) degradation products, and longer PT and APTT values.[22]

A total of 7 (20.6%) transfused patients were suffering from COVID-19–related acute kidney injury (AKI). Batlle et al. commented that AKI in COVID-19 appears to involve a complex process driven by virus-mediated injury, cytokine storm, angiotensin II pathway activation, dysregulation of complement, hypercoagulation, and microangiopathy interacting with common and known risk factors for AKI.[23]

IL-6 and CRP have been associated with severity of COVID-19 with higher values predicting respiratory failure and need for ventilator support.[24],[25] We observed that transfused patients had mean IL-6 and CRP values of 120.8 pg/mL and 10.9 mg/dL, respectively. Previous authors have demonstrated that 60%–90% of hospitalized COVID-19 patients have various comorbidities.[26] We observed that comorbidities such as hypertension (54.4%), diabetes (26.3%), and cardiovascular ailments (39.1%) were common in our COVID-19–transfused patients. A total of 31 (91.2%) transfused patients presented with one or multiple comorbidities. In addition, we observed that 88.2% of the transfused patients were severe or critical and admitted in the hospital COVID ICU or HDU. Richardson et al. observed that up to 40% patients require ICU admission and mortality rates vary across cohorts, reflecting differences in the completeness of testing and case identification, variable thresholds for hospitalization, and differences in outcomes.

LOS in COVID-19 was investigated by previous authors, and various reports have been submitted.[27] Liu et al. reported that COVID-19 patients with pneumonia were discharged sooner than those with severe cases.[28] As most of the transfused patients in the present study were severe or critical, we observed a median LOS of 19.2 days (7–38 days) which is in accordance with previous report. Although we observed a rise in trend in utilization of PRBC and RDP from the month of March 2020 to latter half of June 2020 with a dip in July 2020, the usage of plasma and Cryo had vacillating trends. This may be due to the fact that coagulopathy in COVID-19 is uncommon and therefore utilization of plasma and plasma products varies and depends on hospitalization of these patients. Demonstrating the trends in the number of COVID-19 patients receiving blood components, 12 patients received PRBC and plasma in May 2020 as compared to 8 in July 2020. However, more patients required PLT concentrates in the month of June 2020 compared to other months. These findings may vary between various hospitals and truly depend on the number of hospitalized COVD-19 patients requiring blood transfusion in a particular period.


  Conclusion Top


In conclusion, blood utilization in COVID-19 patients is usually low and does not affect the blood inventory significantly. Elderly critical patients may require blood component therapy due to anemia, thrombocytopenia, and coagulopathy. Often, the trend in blood utilization in COVID-19 patients is difficult to ascertain, and patients may require transfusion of multiple blood components depending on disease severity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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