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Strauss RG, Levy GJ, Sotelo-Avila C, Albanese MA, Hume H, Schloz L, Blazina J, Werner A, Barrasso C, Blanchette V. National survey of neonatal transfusion practices: II. Blood component therapy. Pediatrics 1993; 91:530-6. [PMID: 8382782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Neonatal transfusion practices during 1989 of 452 institutions involved in transfusing infants were surveyed by questionnaire. Most respondents (77%) transfused fresh frozen plasma appropriately (ie, primarily to treat coagulation disorders). However, 11% stated that their most frequent use of fresh frozen plasma was solely to treat hypovolemia, a practice generally not recommended. Seventy-eight percent of respondents transfused platelets to treat bleeding infants with blood platelet counts of less than 50 x 10(9)/L; 84% gave platelets to sick, premature neonates with counts of less than 50 x 10(9)/L whether or not bleeding was evident. Only 35% of respondents transfused granulocytes for neonatal sepsis; most institutions used buffy coats isolated from units of blood--a product readily available, but of questionable efficacy when compared with leukapheresis granulocytes. Ninety-three percent of respondents provided blood components with low risk of transmitting cytomegalovirus: components from seronegative donors were used by 84%, leukocyte-reduced products by 6%, and a combination by 10%. Thirteen percent of respondents gave gamma-irradiated blood components to all and 46% gave them to some neonates to prevent graft vs host disease. Forty-one percent did not routinely irradiate. Ten percent of respondents used leukocyte reduction instead of gamma irradiation to prevent graft vs host disease, a practice currently not advocated. Thus, national transfusion practices for neonates are variable, controversial, and, occasionally, other than those usually recommended. Additional research and educational efforts are needed to ensure optimal transfusion therapy.
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152
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Blanchette VS, Hume HA, Levy GJ, Luban NL, Strauss RG. [Recommendations for controlling transfusions in pediatrics]. GEMATOLOGIIA I TRANSFUZIOLOGIIA 1993; 38:33-7. [PMID: 8020735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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153
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Levy GJ, Strauss RG, Hume H, Schloz L, Albanese MA, Blazina J, Werner A, Sotelo-Avila C, Barrasso C, Blanchette V. National survey of neonatal transfusion practices: I. Red blood cell therapy. Pediatrics 1993; 91:523-9. [PMID: 8441554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Neonatal blood component transfusion practices during 1989 were surveyed via a questionnaire developed by the Pediatric Hemotherapy Committee of the American Association of Blood Banks. Of 1790 questionnaires mailed, 452 were selected to form the database for this analysis because they were from institutions in which neonates were transfused. Nearly all institutions contained intensive care units directed by neonatologists and were involved in the management of high-risk infants. Results from institutions serving as the primary pediatric teaching hospital of a medical school were compared with those with no medical school affiliation. Thirty-six percent of primary pediatric teaching hospitals and 52% of hospitals with no medical school affiliation performed pretransfusion testing in excess of that required, resulting in additional blood loss in neonates. Sixty-six percent of primary pediatric teaching hospitals used fresh frozen plasma to adjust the hematocrit of red blood cell concentrates prior to transfusion (a practice increasing donor exposure), compared with only 29% of hospitals with no medical school affiliation. The usual indication for small-volume red blood cell transfusions in severely ill neonates was to maintain a desired hematocrit level, whereas for stable infants, red blood cell transfusions were given to treat symptomatic anemia, rather than to maintain a predetermined hematocrit. As found in 1985, neonatal transfusion practices in 1989 were variable. However, improvements have occurred since 1985 to suggest that further research and educational efforts may serve to promote even better neonatal transfusion therapy.
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154
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Strauss RG, Blanchette VS, Hume H, Levy GJ, Schloz L, Blazina JF, Werner AL, Sotelo-Avila C, Barrasso C, Hines D. National acceptability of American Association of Blood Banks Pediatric Hemotherapy Committee guidelines for auditing pediatric transfusion practices. Transfusion 1993; 33:168-71. [PMID: 8430458 DOI: 10.1046/j.1537-2995.1993.33293158052.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
In 1989, guidelines for the auditing of pediatric transfusion practices were developed by the Pediatric Hemotherapy Committee of the American Association of Blood Banks (AABB) and made available to AABB members. A survey of members who requested the guidelines was conducted to determine how consistent the guidelines were with local transfusion practices and how useful they were for the conduct of audits. The majority of respondents indicated that the recommended audit criteria agreed with local practices and that most of them could be applied to their transfusion practice audits with little or no modification. An exception was that criteria for the transfusion of platelets to premature infants were considered by some to be too liberal. However, after review of the comments and the published information available, the committee elected not to revise the guidelines pertaining to platelet transfusions for premature infants. Bearing in mind that audit criteria are intended to identify circumstances in which transfusions are acceptable as reasonable therapy without need for further justification, rather than to serve as indications for transfusions, the AABB Pediatric Hemotherapy Committee guidelines for auditing pediatric transfusion practices are fairly representative of national practice.
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McLeod BC, Strauss RG, Ciavarella D, Gilcher RO, Kasprisin DO, Kiprov DD, Klein HG. Management of hematological disorders and cancer. J Clin Apher 1993; 8:211-30. [PMID: 8113208 DOI: 10.1002/jca.2920080404] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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156
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Kiprov DD, Strauss RG, Ciavarella D, Gilcher RO, Kasprisin DO, Klein HG, McLeod BC. Management of autoimmune disorders. J Clin Apher 1993; 8:195-210. [PMID: 8113207 DOI: 10.1002/jca.2920080403] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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157
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Gilcher RO, Strauss RG, Ciavarella D, Kasprisin DO, Kiprov DD, Klein HG, McLeod BC. Management of renal disorders. J Clin Apher 1993; 8:258-69. [PMID: 8113210 DOI: 10.1002/jca.2920080407] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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158
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Strauss RG, Ciavarella D, Gilcher RO, Kasprisin DO, Kiprov DD, Klein HG, McLeod BC. An overview of current management. J Clin Apher 1993; 8:189-94. [PMID: 8113206 DOI: 10.1002/jca.2920080402] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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159
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Kasprisin DO, Strauss RG, Ciavarella D, Gilcher RO, Kiprov DD, Klein HG, McLeod BC. Management of metabolic and miscellaneous disorders. J Clin Apher 1993; 8:231-41. [PMID: 8113209 DOI: 10.1002/jca.2920080405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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160
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Ciavarella D, Wuest D, Strauss RG, Gilcher RO, Kasprisin DO, Kiprov DD, Klein HG, McLeod BC. Management of neurologic disorders. J Clin Apher 1993; 8:242-57. [PMID: 7906690 DOI: 10.1002/jca.2920080406] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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161
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Grishaber JE, Cordle DG, Strauss RG. Development of alloanti-Jka in a patient with hemolytic anemia due to autoanti-Jkb. Am J Clin Pathol 1992; 98:542-4. [PMID: 1485608 DOI: 10.1093/ajcp/98.5.542] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Autoanti-Jkb and a transient autoanti-E were identified in a patient with autoimmune hemolytic anemia, and red blood cells negative for Jkb and E antigens were transfused. Twelve weeks after transfusion, the autoantibody appeared to have developed broad specificity. However, autoadsorption studies revealed that the broad reactivity was due to the development of alloanti-Jka in addition to the autoanti-Jkb. Distinguishing this combination of alloanti-Jka plus autoanti-Jkb from an autoantibody with broad specificity will be important in selecting Jka antigen-negative red cells for subsequent transfusions. This case emphasizes the importance of additional serologic testing to detect alloantibodies in patients with broadly reactive warm autoantibodies.
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Strauss RG, Wieland MR, Randels MJ, Koerner TA. Feasibility and success of a single-donor red cell program for pediatric elective surgery patients. Transfusion 1992; 32:747-9. [PMID: 1412682 DOI: 10.1046/j.1537-2995.1992.32893032103.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Although the risks of allogeneic blood transfusions are small, it is wise to limit donor exposure whenever possible. A program has been developed in which one donor provided all red cell (RBC) units for each patient awaiting elective surgery. Patients were mostly children who were ineligible for autologous blood donation. Seventy-three patients and 115 donors (mostly parents) entered the program. Of the 115 donors, 90 (78%) were eligible to participate and 25 (22%) were ineligible; 21 were ineligible because of RBC incompatibility. For each of the 73 patients, one eligible donor was selected to donate all RBC units. Preoperative RBC orders were 1 to 2 units for 41 patients and > or = 3 units for 32 patients. Of the 73 donors, 58 (79%) gave all RBC units ordered; 15 (21%) failed to complete all donations, but only 1 because of anemia (hematocrit < 33% [0.33]). Of 73 patients entered, 46 (63%) underwent transfusion, and 27 (37%) did not. Of 46 patients transfused, 38 (83%) received only single-donor RBCs. Thus, the RBC needs of nearly all pediatric elective surgery patients were provided by a single donor for each patient. Single-donor blood programs should be considered for elective surgery patients who are ineligible for autologous blood donation and who would otherwise be exposed to multiple donors.
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164
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Toy PT, McVay PA, Strauss RG, Stehling LC, Ahn DK. Improvement in appropriate autologous donations with local education: 1987 to 1989. Transfusion 1992; 32:562-4. [PMID: 1502710 DOI: 10.1046/j.1537-2995.1992.32692367202.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Preoperative autologous blood donation for elective surgery patients at university hospitals was underused in the past. More recently, national educational efforts have been made. To test the impact of local surgeon interviews and education, in 1988 the same local educational program was instituted at three university hospitals; three community hospitals were used as controls. Donation by appropriate patients of interviewed surgeons (elective surgery, crossmatch recommended, no contraindications to donation) increased from 24 percent (44/180) to 40 percent (88/222) (p = 0.002) and 15 percent (21/143) to 32 percent (41/127) (p = 0.001) at two university hospitals where the investigator-educators were on site, but not at the three community hospitals. Between 1987 and 1989, donation rates at all six hospitals remained low among patients for whom autologous donation was (probably) less appropriate. Donation rates for type and screen procedures were 3.0 percent (131/4587) in 1987 and 3.0 percent (199/6606) in 1989 (p = 0.67). Donation rates for "no blood order" procedures were 0.2 percent (15/9429) in 1987 and 0.1 percent (9/11,239) in 1989 (p = 0.14). It can be concluded that appropriate autologous blood donations increased at university hospitals where surgeons were individually interviewed and educated by an investigator on site. However, despite this increase, apparently eligible elective surgery patients in 1989 still failed to donate. This situation deserves additional investigation.
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165
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Reznicek MJ, Cordle DG, Strauss RG. A hemolytic reaction implicating Sda antibody missed by immediate spin crossmatch. Vox Sang 1992; 62:173-5. [PMID: 1609519 DOI: 10.1111/j.1423-0410.1992.tb01193.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Anti-Sda, an antibody not usually considered to cause of hemolytic transfusion reactions, possibly was related to hemolysis following transfusion of red blood cells expressing strong Sda antigen. Prior to transfusion, the antiglobulin antibody screen performed in LISS and an immediate spin crossmatch were negative. Retrospectively, after hemolysis was detected, an antiglobulin crossmatch with red cells from the transfused unit revealed microscopic incompatibility. The transfused unit proved to have strong expression of Sda antigen-facilitating identification of a weak Sda antibody in our patient. In addition, this case represents an unusual instance in which an antibody screen plus an immediate spin crossmatch failed to detect an incompatibility that would have been apparent had an antiglobulin crossmatch been performed.
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166
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Strauss RG. Case Analysis Approach to Neonatal Transfusions. Lab Med 1992. [DOI: 10.1093/labmed/23.4.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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167
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Grishaber JE, Cunningham MC, Rohret PA, Strauss RG. Analysis of venous access for therapeutic plasma exchange in patients with neurological disease. J Clin Apher 1992; 7:119-23. [PMID: 1286989 DOI: 10.1002/jca.2920070304] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We retrospectively analyzed our 2-year experience with venous access for 363 therapeutic plasma exchanges in 46 patients with neurological disease, including acute Guillain-Barré syndrome (N = 20), myasthenia gravis (N = 17), and chronic inflammatory demyelinating polyneuropathy (N = 9). Twenty-three patients (50%) completed the planned course of therapy using only peripheral venous access, and 28 central venous catheters were placed in the remaining 23 patients. Patients utilizing central venous access did not undergo a greater number of procedures, but they were more likely to have acute Guillain-Barré syndrome (P < 0.02) or to be hospitalized in a medical intensive care unit (P < 0.01). Three types of central catheters were used, and although our experience was predominantly with 1 type, differences were noted. Only 3% of procedures (3 of 96) done with a Quinton-Mahurkar catheter were associated with a catheter failure, compared to 27% (4 of 15, P < 0.01) with a Hickman catheter and 67% (2 of 3) with a triple-lumen catheter. Life-threatening complications occurred with 3 of 28 (11%) central catheters. To optimize the success of therapeutic plasma exchange using central access, it is critical that hemapheresis personnel advise each patient's primary physician regarding the type of central venous catheter required. Currently, we recommend use of a Quinton-Mahurkar or other dual-lumen hemodialysis catheter.
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168
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Strauss RG. Autologous transfusions for neonates using placental blood. A cautionary note. AMERICAN JOURNAL OF DISEASES OF CHILDREN (1960) 1992; 146:21-2. [PMID: 1736643 DOI: 10.1001/archpedi.1992.02160130023013] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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169
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Randels MJ, Strauss RG, Cordle D, Koerner TA, Floss AS. Donor reactions during DDAVP-stimulated plasmapheresis. J Clin Apher 1992; 7:78-80. [PMID: 1429492 DOI: 10.1002/jca.2920070208] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Donor exposure can be strikingly reduced for patients with classical hemophilia A and von Willebrand's disease when large volumes of potent cryoprecipitated AHF are prepared from donors following DDAVP (1-deamino-8-D-arginine vasopressin) stimulation and automated plasmapheresis--a procedure called "plasma exchange donation." Although this procedure has been reported to be relatively safe for donors, data are limited. Accordingly, we studied 20 donors during 48 procedures using DDAVP (0.3 micrograms/kg IV) followed by 2-3 L plasma collection. Replacement fluid for each initial plasma exchange donation was plasma protein fraction; autologous cryoprecipitate-poor plasma was used for subsequent procedures. Mild reactions, particularly facial flushing, were noted in all 48 procedures. No procedure was discontinued, but four were modified due to either an increased pulse rate (> or = 20/min from baseline) or a fall in systolic or diastolic blood pressure (> or = 20 mm Hg from baseline). No donor was deferred or withdrew from the program. Based on our modest experience, DDAVP stimulated plasma exchange donation appears to be a safe and effective method for collecting large quantities of plasma from which potent cryoprecipitated AHF can be prepared.
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170
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Reznicek MJ, Cordle DG, Strauss RG. A Hemolytic Reaction Implicating Sd^a Antibody Missed by
Immediate Spin Crossmatch. Vox Sang 1992. [DOI: 10.1159/000462193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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171
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Toy PT, Kaplan EB, McVay PA, Lee SJ, Strauss RG, Stehling LC. Blood loss and replacement in total hip arthroplasty: a multicenter study. The Preoperative Autologous Blood Donation Study Group. Transfusion 1992; 32:63-7. [PMID: 1731438 DOI: 10.1046/j.1537-2995.1992.32192116435.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To determine blood loss, the number of transfusions, and the hemoglobin levels achieved in patients via transfusion in the course of total hip arthroplasty, 324 patient records from 1987 through 1989 were reviewed at three university and three community hospitals. Calculated blood loss was 3.2 +/- 1.3 units in primary procedures and 4.0 +/- 2.1 units in revision procedures (mean +/- SD). Of 777 red cell units transfused, 455 (59%) were autologous units. Transfused patients received 2.0 +/- 1.8 units for primary procedures and 2.9 +/- 2.3 units for revision procedures (mean +/- SD). The maximum number of units given to 95 percent of the transfused patients was 4 for primary procedures and 6 for revision procedures. The mean postoperative hemoglobin level after all transfusions was 103 to 110 g per L, regardless of patient age group of physical status, autologous donor status, or hospital. No difference in length of hospital stay was observed for patients less than 65 years old with hemoglobin concentrations of 80 to 139 g per L at discharge.
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172
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McVay PA, Strauss RG, Stehling LC, Toy PT. Probable reasons that autologous blood was not donated by patients having surgery for which crossmatched blood was ordered. Transfusion 1991; 31:810-3. [PMID: 1755085 DOI: 10.1046/j.1537-2995.1991.31992094667.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Preoperative autologous blood donation is used by only a small percentage of surgery patients for whom crossmatched blood is ordered. To document the reasons the patients failed to donate, the medical records of surgical patients at three university and three community hospitals were studied. All procedures for which crossmatched blood was ordered, but for which autologous blood was not available, were included (n = 8121). Probable reasons for nondonation were found in 72 percent of university hospital patients and 65 percent of community hospital patients (n = 6064 and n = 2057, respectively). The most frequent reasons for nondonation among university hospital patients were emergency surgery (27%) and age less than 12 years (17%), and those among community hospital patients were emergency surgery (42%) and American Society of Anesthesiologists physical status greater than or equal to 4 (20%). Surprisingly, anemia (hemoglobin less than 11 g/dL [less than 110 g/L]) as the only limitation to donation was rarely found: this was the sole reason in only 3.3 percent of university hospital and 4.5 percent of community hospital patients. Overall, of 8121 patients who failed to donate autologous blood, 5731 (71%) had legitimate medical reasons. The remaining 2390 (29%) had no identifiable reason for nondonation, and recruitment efforts should be focused on them and their surgeons.
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Abstract
Infants, particularly those who were very small premature neonates, are among the most common of all patient groups to undergo extensive transfusion. It is estimated that approximately 300,000 neonates undergo transfusions annually. Most infants who undergo transfusion are exposed to multiple blood donors, and although each exposure poses only a small risk, the potential for adverse effects of multiple transfusions is not variable, and based on scanty scientific information. For the most part, controlled scientific studies have not been performed to clearly establish the indications for the transfusion of blood components to neonates. Considering these limitations, guidelines are offered for the transfusion of red blood cells, platelets, and neutrophils into neonates.
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174
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Blanchette VS, Hume HA, Levy GJ, Luban NL, Strauss RG. Guidelines for auditing pediatric blood transfusion practices. AMERICAN JOURNAL OF DISEASES OF CHILDREN (1960) 1991; 145:787-96. [PMID: 1647658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Although transfusion of blood products is an essential and potentially life-saving measure, not all blood transfusions are beneficial to patients. The associated risks, particularly transfusion-transmitted viral illnesses, such as hepatitis and acquired immunodeficiency syndrome, require that careful consideration be given before a decision is made to transfuse any blood product. Many institutions have established a local committee to monitor transfusion practices and audit such practices regularly. To assist in this task, the Pediatric Hemotherapy Committee of the American Association of Blood Banks has developed guidelines for the conduct of pediatric blood transfusion audits. These guidelines, summarized herein, cover transfusion of red blood cells, platelets, white blood cells, fresh-frozen plasma, albumin, and clotting concentrates. The use of cytomegalovirus low-risk and irradiated blood products is also discussed. Throughout the report, special attention is given to the transfusion needs of newborn infants.
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175
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Strauss RG. Indications for the transfusion of fresh-frozen plasma during extracorporeal membrane oxygenation. Transfusion 1991; 31:476-7. [PMID: 2048188 DOI: 10.1046/j.1537-2995.1991.31591263208.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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