Transfusion-related adverse reactions reported to the National Healthcare Safety Network Hemovigilance Module, United States, 2010 to 2012

A retrospective cost analysis of the frequency and cost of transfusion premedications

BACKGROUND

Acetaminophen and diphenhydramine are routinely administered to prevent febrile non-hemolytic and allergic blood transfusion reactions despite multiple randomized controlled trials demonstrating that this practice lacks efficacy. As a result, patients are exposed to the adverse effects of these medications and their financial burdens with no expected benefit. The aim of this study was to quantify the frequency and cost of transfusion premedications in patients with acute myeloid leukemia (AML).

STUDY DESIGN AND METHODS

This was a retrospective study of patients with AML admitted to Vanderbilt University Medical Center (VUMC) for induction chemotherapy between January 2008 and December 2016. Data were collected on the number of platelet and packed red blood cell (PRBC) transfusions each patient received during the initial inpatient encounter for AML, as well as on the administration of premedications prior to each transfusion.

RESULTS

During the 9-year study period, 948 AML patients received a total of 19,820 transfusions. Of these, 30% were preceded by oral diphenhydramine, 8% by intravenous diphenhydramine, and 39% by oral acetaminophen. The percentage of patients that received a transfusion preceded by a premedication increased over the study period (p = 0.03), as did the percentage of transfusions preceded by a premedication (p = 0.02). The total unadjusted cost of pre-transfusion medications to the institution during the study period was $50,309.77, or $52.67 per patient with AML. The cost of premedications per patient did not increase over the study period (p = .45).

CONCLUSIONS

Routine transfusion premedication administration is common in AML patients and not well-supported by available evidence.

Optimal route for administering tranexamic acid in primary unilateral total hip arthroplasty: Results from a multicenter cohort study

AIM

This study aimed to compare the efficacy and safety of different tranexamic acid (TXA) routes following primary total hip arthroplasty (THA).

METHODS

We collected data from the National Health Database on patients registered from January 2013 to September 2017. The patients were divided based on TXA administration route into a control group (without TXA), intravenous group, topical group and combined group. The primary outcome was transfusion; secondary outcomes were total blood loss, haemoglobin level, decrease in haemoglobin on postoperative day 3, and incidence of complications.

RESULTS

Data were collected on 7667 primary THA, 4662 with TXA and 3005 without TXA. The transfusion rate was 28.7% in the control group, 12.7% in the topical group, 8.9% in the intravenous group, and 6.1% in the combined group, and the inter-group differences were significant (P < .01). The combined group showed significantly smaller total blood loss (1.23 ± 0.52 L), smaller reduction in haemoglobin level (26.5 ± 11.1 g/L) and higher haemoglobin level on postoperative day 3 (107.0 ± 15.5 g/L) than the other three groups (P < .05). The three TXA groups showed significantly lower incidence of deep vein thrombosis than the control group (0.08% vs 0.47%, P = .001) as well as a lower rate of other complications (0.34% vs 0.67%, P = .044).

CONCLUSION

TXA is effective and safe to decrease blood loss and transfusion following primary THA, regardless of whether it is administered intravenously, topically or both. Intravenous or combined routes may produce better haemostatic effects, so they may be suggested in the absence of contraindications.

Revised international surveillance case definition of transfusion-associated circulatory overload: a classification agreement validation study

BACKGROUND

Transfusion-associated circulatory overload (TACO) is a major cause of transfusion-related morbidity and mortality in countries with well developed transfusion services. The International Society of Blood Transfusion, the International Haemovigilance Network, and AABB (formerly American Association of Blood Banks), have developed and validated a revised definition of TACO.

METHODS

International Haemovigilance Network-member haemovigilance systems (Australia, Austria, Denmark, Finland, Greece, India, Ireland, Italy, Japan, Malta, Netherlands, New Zealand, Norway, Slovenia, United Kingdom and United States) provided cases of respiratory complications categorised by their systems, including clinical parameters listed in the 2017 draft definition (part 1). Individual transfusion professionals were then invited to assess 24 case descriptions according to the draft definition (part 2). Positive and negative agreement and inter-rater agreement (κ) were calculated. Based on validation results, cases were reanalysed and slight adjustments made to yield the final 2018 TACO definition.

FINDINGS

In part 1, 16 (44%) of 36 haemovigilance systems provided 178 cases, including 126 TACO cases. By use of the 2018 definition, 96 (76%) of 126 cases of TACO were in positive agreement. 19 (37%) of 52 cases were recognised as non-TACO respiratory complications. In part 2 (47 experts from 20 countries), moderate all-case agreement (κ=0·43) and TACO-specific agreement (κ=0·54) were observed. Excluding cases missing some clinical information (eg, N terminal pro-brain natriuretic peptide, distinctive chest x-ray findings, and relationship with existing respiratory co-morbidities like pneumonia and chronic obstructive pulmonary disease) improved all-case agreement to κ=0·50 (moderate) and κ=0·65 (good) for TACO cases.

INTERPRETATION

The two-part validation exercise showed that the revised 2018 TACO surveillance case definition captures 76% of cases endorsed as TACO by participating haemovigilance systems. This definition can become the basis for internationally consistent surveillance reporting and contribute towards increased awareness and mitigation of TACO. Further research will require reporting more complete clinical information to haemovigilance systems and should focus on improved distinction between TACO and other transfusion respiratory complications.

FUNDING

International Society of Blood Transfusion, International Haemovigilance Network, and AABB.

Noninfectious transfusion-associated adverse events and their mitigation strategies

Blood transfusions are life-saving therapies; however, they can result in adverse events that can be infectious or, more commonly, noninfectious. The most common noninfectious reactions include febrile nonhemolytic transfusion reactions, allergic transfusion reactions, transfusion-associated circulatory overload, transfusion-related acute lung injury, and acute and delayed hemolytic transfusion reactions. These reactions can be asymptomatic, mild, or potentially fatal. There are several new methodologies to diagnose, treat, and prevent these reactions. Hemovigilance systems for monitoring transfusion events have been developed and demonstrated decreases in some adverse events, such as hemolytic transfusion reactions. Now vein-to-vein databases are being created to study the interactions of the donor, product, and patient factors in the role of adverse outcomes. This article reviews the definition, pathophysiology, management, and mitigation strategies, including the role of the donor, product, and patient, of the most common noninfectious transfusion-associated adverse events. Prevention strategies, such as leukoreduction, plasma reduction, additive solutions, and patient blood management programs, are actively being used to enhance transfusion safety. Understanding the incidence, pathophysiology, and current management strategies will help to create innovative products and continually hone in on best transfusion practices that suit individualized patient needs.

Anaemia requiring red blood cell transfusion is associated with unfavourable 90-day survival in surgical patients with sepsis

Objective

The mortality associated with sepsis remains unacceptably high, despite modern high-quality intensive care. Based on the results from previous studies, anaemia and its management in patients with sepsis appear to impact outcomes; however, the transfusion policy is still being debated, and the ideal approach may be extremely specific to the individual. This study aimed to investigate the long-term impact of anaemia requiring red blood cell (RBC) transfusion on mortality and disease severity in patients with sepsis. We studied a general surgical intensive care unit (ICU) population, excluding cardiac surgery patients. 435 patients were enrolled in this observational study between 2012 and 2016.

Results

Patients who received RBC transfusion between 28 days before and 28 days after the development of sepsis (n = 302) exhibited a significantly higher 90-day mortality rate (34.1% vs 19.6%; P = 0.004, Kaplan–Meier analysis). This association remained significant after adjusting for confounders in the multivariate Cox regression analysis (hazard ratio 1.68; 95% confidence interval 1.03–2.73; P = 0.035). Patients who received transfusions also showed significantly higher morbidity scores, such as SOFA scores, and ICU lengths of stay compared to patients without transfusions (n = 133). Our results indicate that anaemia and RBC transfusion are associated with unfavourable outcomes in patients with sepsis.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3988-z) contains supplementary material, which is available to authorized users.

Comparison of three routes of administration of tranexamic acid in primary unilateral total knee arthroplasty: Analysis of a national database

INTRODUCTION

The ideal route for the administration of tranexamic acid (TXA) remains undecided. This study aimed to compare the efficacy and safety of three routes of TXA following primary total knee arthroplasty (TKA).

MATERIALS AND METHODS

We prospectively collected patients' data through the National Health Database from January 2013 to September 2017. The patients were divided into a control group, intravenous group, topical group, and combined group according to the different routes of TXA. The primary outcome was the incidence of transfusion, and secondary outcomes were total blood loss, hemoglobin level and extent of hemoglobin decrease on postoperative day 3, and incidence of complications.

RESULTS

Of the total of 7133 primary TKA procedures collected, 4201 employed TXA and 2932 did not. The transfusion rate was 19.8% in the control group and 7.5% in the topical group, significantly higher than that in the intravenous (4.0%, p < 0.001) and combined (4.2%, p < 0.01) groups. The topical group had higher blood loss (0.97 ± 0.47 L), greater reduction in hemoglobin level (31.2 ± 10.1 g/L), and lower hemoglobin level (102.6 ± 12.7 g/L) on postoperative day 3, compared with the intravenous and combined groups (p < 0.05 for all). The differences between the intravenous and combined groups were not significant (p > 0.05). The incidence of deep vein thrombosis in the topical group (1.1%) was significantly higher than that in the control (0.4%, p = 0.007) and intravenous groups (0.3%, p = 0.003).

CONCLUSION

Intravenous and combined administration of TXA was equivalent in reducing blood loss and transfusion requirement, and superior to topical routes.

Evaluation of the National Healthcare Safety Network Hemovigilance Module for transfusion-related adverse reactions in the United States

INTRODUCTION

The National Healthcare Safety Network (NHSN) Hemovigilance Module (HM) collects data on the frequency, severity, and imputability of transfusion-associated adverse events. These events contribute to significant morbidity and mortality among transfusion patients. We report results from the first systematic assessment of eight attributes of the HM.

MATERIALS AND METHODS

Standard methods were used to assess the HM. Evaluation data included training materials, system modification history, and facility survey information. A concordance analysis was performed using data from the Baystate Medical Center's (Springfield, MA) electronic transfusion reporting system.

RESULTS

In 2016, system representativeness remained low, with 6% (277 of 4690) of acute care facilities across 43 jurisdictions enrolled in the HM. In 2016, 48% (2147 of 4453) and 89% (3969 of 4,453) of adverse reactions were reported within 30 and 90 days of the reaction date, respectively, compared to 21% (109 of 511) and 56% (284 of 511) in 2010, demonstrating improved reporting timeliness. Data quality from most reactions was adequate, with 10% (45 of 442) misclassified transfusion-associated circulatory overload reactions, and no incomplete transfusion-transmitted infection data reported from 2010 to 2013. When compared to the Baystate system to assess concordance, 43% (24 of 56) of NHSN-reported febrile reactions were captured in both systems (unweighted kappa value, 0.47; confidence interval, 0.33-0.61).

CONCLUSION

Since the 2010 HM pilot, improvements have led to enhanced simplicity, timeliness, and strengthened data quality. The HM serves an important and unique role despite incomplete adoption nationwide. Facility efforts to track and prevent transfusion-associated adverse events through systems like the NHSN HM are a key step toward improving transfusion safety in the United States.

Intraoperative Diagnosis and Management of Acute Hypotensive Blood Transfusion Reaction (AHTR): A Report of Two Cases

Case series

Patients: Female, 68 • Male, 86

Final Diagnosis: Acute hypotensive transfusion reaction

Symptoms: Hypotension

Medication: —

Clinical Procedure: —

Specialty: Anesthesiology

Centrifugation-free washing: A novel approach for removing immunoglobulin A from stored red blood cells

Washed red blood cells (RBCs) are indicated for immunoglobulin A (IgA) deficient recipients. Centrifugation-based cell processors commonly used by hospital blood banks cannot consistently reduce IgA below the recommended levels, hence double washing is frequently required. Here, we describe a prototype of a simple, portable, disposable system capable of washing stored RBCs without centrifugation, while reducing IgA below 0.05 mg/dL in a single run. Samples from RBC units (n = 8, leukoreduced, 4-6 weeks storage duration) were diluted with normal saline to a hematocrit of 10%, and then washed using either the prototype washing system, or via conventional centrifugation. The efficiency of the two washing methods was quantified and compared by measuring several key in vitro quality metrics. The prototype of the washing system was able to process stored RBCs at a rate of 300 mL/hour, producing a suspension of washed RBCs with 43 ± 3% hematocrit and 86 ± 7% cell recovery. Overall, the two washing methods performed similarly for most measured parameters, lowering the concentration of free hemoglobin by >4-fold and total free protein by >10-fold. Importantly, the new washing system reduced the IgA level to 0.02 ± 0.01 mg/mL, a concentration 5-fold lower than that produced by conventional centrifugation. This proof-of-concept study showed that centrifugation may be unnecessary for washing stored RBCs. A simple, disposable, centrifugation-free washing system could be particularly useful in smaller medical facilities and resource limited settings that may lack access to centrifugation-based cell processors.

Adverse Events Associated With Infusion of Hematopoietic Stem Cell Products: A Prospective and Multicenter Surveillance Study

Adverse events (AEs) associated with blood transfusions, including component-specific red cell, platelet, and plasma products, have been extensively surveyed. In contrast, surveillance of AEs associated with hematopoietic stem cell (HSC) products in HSC transplantation (HSCT) has been less rigorous, even though HSC products include a diversity of immature and mature hematopoietic cells, substantial plasma, and dimethyl sulfoxide (DMSO) in the case of cryopreserved HSC products. HSC infusion-related AEs have been attributed to DMSO toxicity, but AEs associated with the infusion of noncryopreserved HSC products are not uncommon. To quantify the frequencies, types, and risk factors of HSC infusion-related AEs, we implemented national surveillance for AEs observed within 24 hours after infusion. Herein we report on 1125 HSCTs, including 570 peripheral blood stem cell transplantations (PBSCTs) (290 autologous [auto-] and 280 allogeneic [allo-]), 332 allo-bone marrow transplantations (allo-BMTs) and 223 allo-cord blood transplantations (allo-CBTs). Unexpectedly, incidences of grade ≥ 2 AEs were most frequent in allo-BMTs (37.7%) with no DMSO in any product compared with auto-/allo-PBSCTs (20.9%, P < .001) and allo-CBTs (19.3%, P < .001) typically cryopreserved with DMSO. Hypertension was most often noted in BMTs, whereas nausea/vomiting, fever, and allergic reactions were most frequent in allo-PBSCTs. In a multivariate analysis, a history of transfusion reactions was a risk factor for overall AEs in all HSCTs (odds ratio [OR] = 1.459, P = .045). For grade ≥ 2 AEs in allo-HSCTs, a history of transfusion reactions (OR = 1.551, P = .044) for overall AEs, and high infusion volume (OR = 7.544, P = .005) and allo-PBSCTs (versus BMTs, OR = 9.948, P = .002) for allergic reactions were identified as risk factors. These findings suggest that some factors unrelated to DMSO, such as allo-antigens, contribute to HSC infusion-related AEs. As severe AEs, a total of 117 grade ≥ 3 AEs were reported in 1125 HSCTs, including life-threatening complications in 3 (0.3%) HSCTs: 1 allo-CBT (anaphylaxis) and 2 allo-PBSCTs (hypoxia, kidney injury) with cryopreserved product. Our data show that HSC infusion risks vary by product, can be severe, and should be monitored with the same rigor as modern transfusion hemovigilance programs.

Platelets directly regulate DNA damage and division of Staphylococcus aureus

Platelets (PLTs) are classically used in the clinical setting to maintain hemostasis. Recent evidence supports important roles for PLTs in host inflammatory and immune responses, and PLT-rich plasma has been demonstrated to inhibit the growth of bacteria in vitro and in vivo; however, few studies have examined whether PLTs can inhibit bacterial growth directly, and related mechanisms have not been elucidated further. Accordingly, in this study, we evaluated the effects of PLTs on bacterial growth. We washed and purified PLTs from peripheral blood, then confirmed that PLTs significantly inhibited the growth of Staphylococcus aureus when cocultured in vitro. Moreover, PLTs damaged DNA and blocked cell division in S. aureus. During coculture, PLT-derived TGF-β1 was dramatically down-regulated compared with that in PLT culture alone, and the addition of TGF-β1 to the coculture system promoted the inhibition of PLTs on S. aureus. Analysis of a murine S. aureus infection model demonstrated that the depletion of PLTs exacerbated the severity of infection, whereas the transfusion of PLTs alleviated this infection. Our observations demonstrate that PLTs could directly inhibit the growth of S. aureus by damaging DNA and blockage cell division, and that PLT-derived TGF-β1 may play an important role in this machinery.-Xu, J., Yi, J., Zhang, H., Feng, F., Gu, S., Weng, L., Zhang, J., Chen, Y., An, N., Liu, Z., An, Q., Yin, W., Hu, X. Platelets directly regulate DNA damage and division of Staphylococcus aureus.

Transfusion reactions after transfusion of platelets stored in PAS-B, PAS-C, or plasma: a nationwide comparison

BACKGROUND

Platelets (PLTs) stored in PLT additive solution (PAS) are associated with fewer allergic reactions than plasma-stored PLTs. However, earlier studies could not provide conclusive evidence on febrile reactions and did not analyze other transfusion reactions separately due to limited sample size. We therefore compared incidences of all transfusion reactions of PAS-B-PLTs, PAS-C-PLTs, and plasma-PLTs.

STUDY DESIGN AND METHODS

In this observational study, all transfusion reactions reported to the national hemovigilance office of the Netherlands from 2006 to 2015 were included.

RESULTS

During the study period, a total of 2407 transfusion reactions after PLT transfusions were reported. In that period 553,267 pooled buffy coat-derived PLT units were issued, of which 83,884 were stored in PAS-B, 45,728 in PAS-C, and 423,655 in plasma. Regarding transfusion-related circulatory overload, transfusion-related acute lung injury, and "other reactions" no significant differences were observed between the PLT products. When PAS-B-PLT transfusions were compared to plasma-PLT transfusions, the overall relative risk (RR; 95% confidence interval [CI]) of transfusion reactions was 0.99 (0.88-1.11); for allergic and febrile nonhemolytic transfusion reactions (FNHTRs) it was 0.66 (0.55-0.80) and 1.54 (1.27-1.86), respectively. When PAS-C-PLTs were compared to plasma-PLTs, the RR (95% CI) was 0.56 (0.46-0.68) for all transfusion reactions, 0.38 (0.28-0.52) for allergic reactions, and 0.82 (0.59-1.13) for FNHTRs. When PAS-C-PLTs were compared to PAS-B-PLTs, for all reactions the RR (95% CI) was 0.56 (0.45-0.70) for allergic reactions 0.58 (0.40-0.82), and for FNHTRs 0.53 (0.37-0.75).

CONCLUSIONS

PAS-C-PLTs are associated with fewer transfusion reactions compared to plasma-PLTs and compared to PAS-B-PLTs.

Plasma Transfusion Demystified: A Review of the Key Factors Influencing the Response to Plasma Transfusion

Many studies have suggested that inappropriate plasma usage is common. An important factor contributing to futile plasma administration in most patients is the nonlinear relationship between coagulation-factor levels and the volume of plasma transfused. In this review, a validated mathematical model and data from the literature will be used to illuminate 3 key properties of plasma transfusion. Those properties are as follows: the effect of plasma transfusion on international normalized ratio (INR) is transient; for the same volume of transfused plasma, a greater reduction in INR is observed at higher initial INRs; and the effect of plasma transfusion on INR correction (ie, the difference between initial and final INRs) diminishes as more plasma is transfused. Frequent misunderstanding of these properties may contribute to inappropriate plasma usage. Therefore, this review will assist physicians in navigating these common pitfalls. Stronger understanding of these principles may result in a reduction of inappropriate plasma transfusions, thus potentially enhancing patient safety and reducing healthcare costs.

Demographic and epidemiologic characterization of transfusion recipients from four US regions: evidence from the REDS-III recipient database

BACKGROUND

Blood transfusion is one of the most common medical procedures during hospitalization in the United States. To understand the benefits of transfusion while mitigating potential risks, a multicenter database containing detailed information on transfusion incidence and recipient outcomes would facilitate research.

STUDY DESIGN AND METHODS

The Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) program has developed a comprehensive transfusion recipient database utilizing data from hospital electronic health records at 12 participating hospitals in four geographic regions. Inpatient and outpatient data on transfusion recipients from January 1, 2013 to December 31, 2014 included patient age, sex, ethnicity, primary diagnosis, type of blood product provided, issue location, pretransfusion and post-transfusion hemoglobin (Hgb), and hospital outcomes. Transfusion incidence per encounter was calculated by blood product and various patient characteristics.

RESULTS

During the 2-year study period, 80,362 (12.5%) inpatient encounters involved transfusion. Among inpatients, the most commonly transfused blood products were red blood cells (RBCs; 10.9% of encounters), followed by platelets (3.2%) and plasma (2.9%). Among patients who received transfusions, the median number of RBC units was one, the pretransfusion Hgb level was 7.6 g/dL, and the Hgb increment per unit was 1.4 g/dL. Encounter mortality increased with patient age, the number of units transfused, and the use of platelet or plasma products. The most commonly reported transfusion reaction was febrile nonhemolytic.

CONCLUSION

The database contains comprehensive data regarding transfusion use and patient outcomes. The current report describes an evaluation of the first 2 years of a planned, 4-year, linked blood donor-component-recipient database, which represents a critical new resource for transfusion medicine researchers.

Analysis of pediatric adverse reactions to transfusions

BACKGROUND

Children are known to be physiologically and biochemically different from adults. However, there are no multi-institutional studies examining the differences in the frequency, type, and severity of transfusion reactions in pediatric versus adult patients. This study aims to characterize differences between pediatric and adult patients regarding adverse responses to transfusions.

STUDY DESIGN AND METHODS

This is a retrospective data analysis of nine children's hospitals and 35 adult hospitals from January 2009 through December 2015. Included were pediatric and adult patients who had a reported reaction to transfusion of any blood component. Rates are reported as per 100,000 transfusions for comparison between pediatric and adult patients.

RESULTS

Pediatric patients had an overall higher reaction rate compared to adults: 538 versus 252 per 100,000 transfusions, notably higher for red blood cell (577 vs. 278 per 100,000; p < 0.001) and platelet (833 vs. 358 per 100,000; p < 0.001) transfusions. Statistically higher rates of allergic reactions, febrile nonhemolytic reactions, and acute hemolytic reactions were observed in pediatric patients. Adults had a higher rate of delayed serologic transfusion reactions, delayed hemolytic transfusion reactions, and transfusion-associated circulatory overload.

CONCLUSION

Pediatric patients had double the rate of transfusion reactions compared to adults. The nationally reported data on reaction rates are consistent with this study's findings in adults but much lower than the observed rates for pediatric patients. Future studies are needed to address the differences in reaction rates, particularly in allergic and febrile reactions, and to further address blood transfusion practices in the pediatric patient population.

Incompatible type A plasma transfusion in patients requiring massive transfusion protocol: Outcomes of an Eastern Association for the Surgery of Trauma multicenter study

With a relative shortage of type AB plasma, many centers have converted to type A plasma for resuscitation of patients whose blood type is unknown. The goal of this study is to determine outcomes for trauma patients who received incompatible plasma transfusions as part of a massive transfusion protocol (MTP).

METHODS

As part of an Eastern Association for the Surgery of Trauma multi-institutional trial, registry and blood bank data were collected from eight trauma centers for trauma patients (age, ≥ 15 years) receiving emergency release plasma transfusions as part of MTPs from January 2012 to August 2016. Incompatible type A plasma was defined as transfusion to patient blood type B or type AB.

RESULTS

Of the 1,536 patients identified, 92% received compatible plasma transfusions and 8% received incompatible type A plasma. Patient characteristics were similar except for greater penetrating injuries (48% vs 36%; p = 0.01) in the incompatible group. In the incompatible group, patients were transfused more plasma units at 4 hours (median, 9 vs. 5; p < 0.001) and overall for stay (11 vs. 9; p = 0.03). No hemolytic transfusion reactions were reported. Two transfusion-related acute lung injury events were reported in the compatible group. Between incompatible and compatible groups, there was no difference in the rates of acute respiratory distress syndrome (6% vs. 8%; p = 0.589), thromboembolic events (9% vs. 7%; p = 0.464), sepsis (6% vs. 8%; p = 0.589), or acute renal failure (8% vs. 8%, p = 0.860). Mortality at 6 (17% vs. 15%, p = 0.775) and 24 hours (25% vs. 23%, p = 0.544) and at 28 days or discharge (38% vs. 35%, p = 0.486) were similar between groups. Multivariate regression demonstrated that Injury Severity Score, older age and more red blood cell transfusion at 4 hours were independently associated with death at 28 days or discharge; Injury Severity Score and more red blood cell transfusion at 4 hours were predictors for morbidity. Incompatible transfusion was not an independent determinant of mortality or morbidity.

CONCLUSION

Transfusion of type A plasma to patients with blood groups B and AB as part of a MTP does not appear to be associated with significant increases in morbidity or mortality.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Continued decline in blood collection and transfusion in the United States-2015

BACKGROUND

In 2011 and 2013, the National Blood Collection and Utilization Survey (NBCUS) revealed declines in blood collection and transfusion in the United States. The objective of this study was to describe blood services in 2015.

STUDY DESIGN AND METHODS

The 2015 NBCUS was distributed to all US blood collection centers, all hospitals performing at least 1000 surgeries annually, and a 40% random sample of hospitals performing 100 to 999 surgeries annually. Weighting and imputation were used to generate national estimates for units of blood and components collected, deferred, distributed, transfused, and outdated.

RESULTS

Response rates for the 2015 NBCUS were 78.4% for blood collection centers and 73.9% for transfusing hospitals. In 2015, 12,591,000 units of red blood cells (RBCs) (95% confidence interval [CI], 11,985,000-13,197,000 units of RBCs) were collected, and 11,349,000 (95% CI, 10,592,000-11,747,000) were transfused, representing declines since 2013 of 11.6% and 13.9%, respectively. Total platelet units distributed (2,436,000; 95% CI, 2,230,000-2,642,000) and transfused (1,983,000; 95% CI, 1,816,000 = 2,151,000) declined by 0.5% and 13.1%, respectively, since 2013. Plasma distributions (3,714,000; 95% CI, 3,306,000-4,121,000) and transfusions (2,727,000; 95% CI, 2,594,000-2,859,000) in 2015 declined since 2013. The median price paid per unit in 2015-$211 for leukocyte-reduced RBCs, $524 for apheresis platelets, and $54 for fresh frozen plasma-was less for all components than in 2013.

CONCLUSIONS

The 2015 NBCUS findings suggest that continued declines in demand for blood products resulted in fewer units collected and distributed Maintaining a blood inventory sufficient to meet routine and emergent demands will require further monitoring and understanding of these trends.

Pathogen reduction/inactivation of products for the treatment of bleeding disorders: what are the processes and what should we say to patients?

Patients with blood disorders (including leukaemia, platelet function disorders and coagulation factor deficiencies) or acute bleeding receive blood-derived products, such as red blood cells, platelet concentrates and plasma-derived products. Although the risk of pathogen contamination of blood products has fallen considerably over the past three decades, contamination is still a topic of concern. In order to counsel patients and obtain informed consent before transfusion, physicians are required to keep up to date with current knowledge on residual risk of pathogen transmission and methods of pathogen removal/inactivation. Here, we describe pathogens relevant to transfusion of blood products and discuss contemporary pathogen removal/inactivation procedures, as well as the potential risks associated with these products: the risk of contamination by infectious agents varies according to blood product/region, and there is a fine line between adequate inactivation and functional impairment of the product. The cost implications of implementing pathogen inactivation technology are also considered.

Clinical Pattern in Hypotensive Transfusion Reactions

BACKGROUND

Hypotensive transfusion reactions (HyTRs) may be underreported and have been associated with patients taking angiotensin-converting enzyme inhibitors (ACEIs) receiving poststorage leukoreduced blood products through negatively charged filters. Although bedside leukoreduction is no longer commonplace, HyTRs still occur and are insufficiently characterized in the prestorage leukoreduction era. We describe recently reported cases at our institution.

METHODS

We reviewed transfusion reaction records at Stanford Healthcare from January 2014 to April 2015. HyTRs were defined by National Health Safety Network Hemovigilance Module classification.

RESULTS

Eleven HyTRs occurred in 10 patients. All were adults (mean age 71.7 years; range 45-92 years), 7 were male, and all underwent major surgery 0 to 2 days before the reaction. Nine patients underwent cardiac or vascular surgery, and all 10 were taking ACEIs with the last dose taken within 48 hours of the transfusion reaction in 9 patients. Nine patients were on extracorporeal circuits within 24 hours before the reaction (median duration 180 minutes; range 87-474 minutes). In 5 reactions, the implicated unit was restarted with resultant recurrent hypotension. Implicated units included 9 packed red blood cells, 1 apheresis platelet, and 1 plasma frozen within 24 hours.

CONCLUSIONS

Contrary to what has been previously reported in the era of prestorage leukoreduction, HyTRs at our institution showed consistent patterns in patients at risk. Patients scheduled to undergo major surgery with cardiopulmonary bypass may benefit from earlier preoperative cessation of ACEIs or temporarily switching to an alternative drug class.

Adverse Reactions to Transfusion of Blood Products and Best Practices for Prevention

Transfusion, a common practice in critical care, is not without complication. Acute adverse reactions to transfusion occur within 24 hours and include acute hemolytic transfusion reaction, febrile nonhemolytic transfusion reaction, allergic and anaphylactic reactions, and transfusion-related acute lung injury, transfusion-related infection or sepsis, and transfusion-associated circulatory overload. Delayed transfusion adverse reactions develop 48 hours or more after transfusion and include erythrocyte and platelet alloimmunization, delayed hemolytic transfusion reactions, posttransfusion purpura, transfusion-related immunomodulation, transfusion-associated graft versus host disease, and, with long-term transfusion, iron overload. Clinical strategies may reduce the likelihood of reactions and improve patient outcomes.

ADAMTS13 test and/or PLASMIC clinical score in management of acquired thrombotic thrombocytopenic purpura: a cost-effective analysis

BACKGROUND

The ADAMTS13 test distinguishes thrombotic thrombocytopenic purpura (TTP) from other thrombotic microangiopathies (TMAs). The PLASMIC score helps determine the pretest probability of ADAMTS13 deficiency. Due to inherent limitations of both tests, and potential adverse effects and cost of unnecessary treatments, we performed a cost-effectiveness analysis (CEA) investigating the benefits of incorporating an in-hospital ADAMTS13 test and/or PLASMIC score into our clinical practice.

STUDY DESIGN AND METHODS

A CEA model was created to compare four scenarios for patients with TMAs, utilizing either an in-house or a send-out ADAMTS13 assay with or without prior risk stratification using PLASMIC scoring. Model variables, including probabilities and costs, were gathered from the medical literature, except for the ADAMTS13 send-out and in-house tests, which were obtained from our institutional data.

RESULTS

If only the cost is considered, in-house ADAMTS13 test for patients with intermediate- to high-risk PLASMIC score is the least expensive option ($4,732/patient). If effectiveness is assessed as measured by the number of averted deaths, send-out ADAMTS13 test is the most effective. Considering the cost/effectiveness ratio, the in-house ADAMTS13 test in patients with intermediate- to high-risk PLASMIC score is the best option, followed by the in-house ADAMTS13 test without the PLASMIC score.

CONCLUSIONS

In patients with clinical presentations of TMAs, having an in-hospital ADAMTS13 test to promptly establish the diagnosis of TTP appears to be cost-effective. Utilizing the PLASMIC score further increases the cost-effectiveness of the in-house ADAMTS13 test. Our findings indicate the benefit of having a rapid and reliable in-house ADAMTS13 test, especially in the tertiary medical center.

Platelet proteins cause basophil histamine release through an immunoglobulin-dependent mechanism

BACKGROUND

A general understanding of allergic transfusion reaction mechanisms remains elusive. Multiple mechanisms have been proposed, but none have been compared experimentally.

STUDY DESIGN AND METHODS

We used histamine release (HR) from healthy human donor basophils to model allergic transfusion reactions. Platelet component supernatant (plasma), platelet lysate, and manipulated platelet lysates (dialyzed, delipidated, trypsinized, mild heat-inactivated, and ultracentrifuged) were used to characterize allergic stimuli. Immunoglobulin-dependent mechanisms were investigated through cell surface immunoglobulin depletion and ibrutinib signaling inhibition. HR induced by platelet mitochondria was compared with HR by platelet lysate with or without DNase treatment.

RESULTS

Robust, dose-responsive HR to platelet lysate was observed in two of eight nulliparous, never-transfused, healthy donors. No HR was observed with plasma. Among manipulated platelet lysates, only trypsin treatment significantly reduced HR (39% reduction; p = 0.008). HR in response to platelet lysate significantly decreased with either cell surface immunoglobulin depletion or ibrutinib pretreatment. Platelet mitochondria induced minimal basophil HR, and DNase treatment did not inhibit platelet lysate-induced HR.

CONCLUSION

Type I immediate hypersensitivity to platelet proteins may be an allergic transfusion reaction mechanism. Prior sensitization to human proteins is not required for basophil responses to platelet proteins. Further study into the relative contributions of hypersensitivity to platelet versus plasma proteins in transfusion is warranted.

Frequency and pattern of noninfectious adverse transfusion reactions at a tertiary care hospital in Korea

Background

Although transfusion is a paramount life-saving therapy, there are multiple potential significant risks. Therefore, all adverse transfusion reaction (ATR) episodes require close monitoring. Using the computerized reporting system, we assessed the frequency and pattern of non-infectious ATRs.

Methods

We analyzed two-year transfusion data from electronic medical records retrospectively. From March 2013 to February 2015, 364,569 units of blood were transfused. Of them, 334,582 (91.8%) records were identified from electronic nursing records. For the confirmation of ATRs by blood bank physicians, patients' electronic medical records were further evaluated.

Results

According to the nursing records, the frequency of all possible transfusion-related events was 3.1%. After the blood bank physicians' review, the frequency was found to be 1.2%. The overall frequency of febrile non-hemolytic transfusion reactions (FNHTRs) to red blood cells (RBCs), platelet (PLT) components, and fresh frozen plasmas (FFPs) were 0.9%, 0.3%, and 0.2%, respectively, and allergic reactions represented 0.3% (RBCs), 0.9% (PLTs), and 0.9% (FFPs), respectively. The pre-storage leukocyte reduction significantly decreased the frequency of FNHTRs during the transfusion of RBCs (P<0.01) or PLTs (P≒0.01).

Conclusions

The frequency of FNHTRs, allergic reactions, and "no reactions" were 22.0%, 17.0%, and 60.7%, respectively. Leukocyte-reduction was associated with a lower rate of FNHTRs, but not with that of allergic reactions. The development of an effective electronic reporting system of ATRs is important in quantifying transfusion-related adverse events. This type of reporting system can also accurately identify the underlying problems and risk factors to further the quality of transfusion care for patients.

Hemovigilance in Massachusetts and the adoption of statewide hospital blood bank reporting using the National Healthcare Safety Network

A collaboration that grew over time between local hemovigilance stakeholders and the Massachusetts Department of Public Health (MDPH) resulted in the change from a paper-based method of reporting adverse reactions and monthly transfusion activity for regulatory compliance purposes to statewide adoption of electronic reporting via the National Healthcare Safety Network (NHSN). The NHSN is a web-based surveillance system that offers the capacity to capture transfusion-related adverse events, incidents, and monthly transfusion statistics from participating facilities. Massachusetts' hospital blood banks share the data they enter into NHSN with the MDPH to satisfy reporting requirements. Users of the NHSN Hemovigilance Module adhere to specified data entry guidelines, resulting in data that are comparable and standardized. Keys to successful statewide adoption of this reporting method include the fostering of strong partnerships with local hemovigilance champions and experts, engagement of regulatory and epidemiology divisions at the state health department, the leveraging of existing relationships with hospital NHSN administrators, and the existence of a regulatory deadline for implementation. Although limitations exist, successful implementation of statewide use of the NHSN Hemovigilance Module for hospital blood bank reporting is possible. The result is standardized, actionable data at both the hospital and state level that can facilitate interfacility comparisons, benchmarking, and opportunities for practice improvement.

Red cell alloimmunisation in patients with different types of infections

Red cell alloantigen exposure can cause alloantibody‐associated morbidity. Murine models have suggested that inflammation modulates red cell alloimmunisation. This study quantifies alloimmunisation risks during infectious episodes in humans. We performed a multicentre case–control study within a source population of patients receiving their first and subsequent red cell transfusions during an 8‐year follow‐up period. Patients developing a first transfusion‐induced red cell alloantibody (N = 505) were each compared with two similarly exposed, but non‐alloimmunised controls (N = 1010) during a 5‐week ‘alloimmunisation risk period’ using multivariate logistic regression analysis. Transfusions during ‘severe’ bacterial (tissue‐invasive) infections were associated with increased risks of alloantibody development [adjusted relative risk (RR) 1·34, 95% confidence interval (95% CI) 0·97–1·85], especially when these infections were accompanied with long‐standing fever (RR 3·06, 95% CI 1·57–5·96). Disseminated viral disorders demonstrated a trend towards increased risks (RR 2·41, 95% CI 0·89–6·53), in apparent contrast to a possible protection associated with Gram‐negative bacteraemia (RR 0·58, 95% CI 0·13–1·14). ‘Simple’ bacterial infections, Gram‐positive bacteraemia, fungal infections, maximum C‐reactive protein values and leucocytosis were not associated with red cell alloimmunisation. These findings are consistent with murine models. Confirmatory research is needed before patients likely to develop alloantibodies may be identified based on their infectious conditions at time of transfusion.

Declining blood collection and utilization in the United States

BACKGROUND

The Department of Health and Human Services National Blood Collection and Utilization Survey (NBCUS) has been conducted biennially since 1997. Data are used to estimate national blood collection and utilization.

STUDY DESIGN AND METHODS

The 2013 Department of Health and Human Services NBCUS is a cross-sectional survey of all US blood collection centers and hospitals as listed in the 2012 American Hospital Association Annual Survey database that perform at least 100 inpatient surgical procedures annually. The study objective was to estimate, with 95% confidence intervals (CIs), the number of blood and blood components collected and transfused in the United States.

RESULTS

In 2013, a total of 14,237,000 whole blood and apheresis red blood cell (RBC) units (95% CI, 13,639,000-14,835,000) were collected with 13,395,000 available for transfusion. Of these, 13,180,000 (95% CI, 12,389,000-13,972,000) whole blood and RBC units were transfused. This represented a 4.4% decline in the number of transfused units compared to 2011. Outdated (i.e., expired without being transfused) whole blood and RBC units declined by 17.3%. Apheresis (2,318,000; 95% CI, 2,154,000-2,482,000) and whole blood-derived platelet (PLT; 130,000; 95% CI, 23,000-237,000) distribution declined in 2013. Total PLT transfusions increased in 2013 (2,281,000) in comparison to 2011 (2,169,000). Total plasma units distributed (4,338,000) and transfused (3,624,000) declined.

CONCLUSION

Both blood collection and utilization have declined, but the gap between collection and utilization is narrowing. As collections decline further and hospitals decrease transfusions and manage products more efficiently, the decline in surplus inventory may be a concern for disaster preparedness or other unexpected utilization needs.

Transfusion monitoring: care practice analysis in a public teaching hospital

Objective

To analyze the process of recording transfusion monitoring at a public teaching hospital.

Methods

A descriptive and retrospective study with a quantitative approach, analyzing the instruments to record transfusion monitoring at a public hospital in a city in the State of Minas Gerais (MG). Data were collected on the correct completion of the instrument, time elapsed from transfusions, records of vital signs, type of blood component more frequently transfused, and hospital unit where transfusion was performed.

Results

A total of 1,012 records were analyzed, and 53.4% of them had errors in filling in the instruments, 6% of transfusions started after the recommended time, and 9.3% of patients had no vital signs registered.

Conclusion

Failures were identified in the process of recording transfusion monitoring, and they could result in more adverse events related to the administration of blood components. Planning and implementing strategies to enhance recording and to improve care delivered are challenging.

Genotype frequency of human neutrophil antigen-3 polymorphisms in the Yi, Han, and Tibetan populations of China

BACKGROUND

Human neutrophil antigen-3 (HNA-3) alloantibodies can cause fatal transfusion-related acute lung injury (TRALI). Most frequencies of SLC44A2 alleles encoding the HNA-3a/b antigens have been established in Han individuals by polymerase chain reaction with sequence-specific priming (PCR-SSP). We sequenced SLC44A2 gene fragments and determined allele frequencies in three ethnicities of China.

STUDY DESIGN AND METHODS

Genomic DNA was extracted from 448 samples of 100 blood donors of Yi ethnicity in Xichang, Liangshan; 248 Han in Nanjing, Jiangsu; and 100 Tibetan in Lhasa, Tibet. A PCR-SSP was applied to determine the phase of two single-nucleotide polymorphisms (SNPs); SLC44A2 haplotypes were constructed.

RESULTS

In the 567 nucleotides of the SLC44A2 gene covered by our sequencing approach in Han individuals, we detected the known 331-44G>A (rs12972963) and 461G>A (rs2288904) polymorphisms. In the 243 nucleotides sequenced in Yi and Tibetan populations, we detected the known 461G>A and 503-15T>C (rs1560711) polymorphisms. A PCR-SSP for the common HNA-3a/b SNP was 100% concordant. The frequencies of the HNA-3a allele were 0.58, 0.66, and 0.69 in Yi, Han (Nanjing), and Tibetan, respectively (0.42, 0.34, and 0.31 for HNA-3b).

CONCLUSIONS

The Yi population of China had the highest frequency of blood donors at risk of harboring anti-HNA-3a compared to any population studied so far. We confirmed that the underlying SLC44A2*2 allele is more common in China than in any European or African populations.

Mathematical model and calculation to predict the effect of prophylactic plasma transfusion on change in international normalized ratio in critically ill patients with coagulopathy

BACKGROUND

Plasma transfusion is often used prophylactically in patients with coagulopathy. However, the doses transfused may not be adequate to normalize hemostatic tests, which are commonly used as surrogate markers in practice. Currently, there is no reliable way to predict the posttransfusion international normalized ratio (INR) after plasma transfusion. Therefore, our aim was to develop and validate a formula that can reliably estimate post-plasma transfusion INR.

STUDY DESIGN AND METHODS

A compartmental model was developed using demographic (sex, height, weight) and laboratory variables (hematocrit [Hct], INRinitial , and plasma volume transfused). The formula was validated using a data set from a multicenter trial conducted between May 2010 and June 2013 in critically ill, nonbleeding patients with coagulopathy, receiving prophylactic plasma transfusions. INR was measured just before and immediately after plasma transfusion.

RESULTS

Initial plasma volume is calculated using the patient's Hct and blood volume (derived from Nadler's formula). The estimated immediate posttransfusion INR is then calculated as [Formula: see text] There was a significant agreement between the model predictions and the actual INR measurements after transfusion. A total of 83% of the predictions were within the acceptable range of variation. Furthermore, there was no proportional difference or systemic bias between the predictions and the actual INR measurements.

CONCLUSION

This mathematical formula estimates posttransfusion INR after a certain volume of plasma transfusion with a good predictive ability. This formula, which only requires basic demographic and laboratory variables, may help the physicians to determine the volume of plasma required for a specific target INR in stable, nonbleeding patients.

Haemovigilance of reactions associated with red blood cell transfusion: comparison across 17 Countries

BACKGROUND AND OBJECTIVES

The recent establishment of the National Healthcare Safety Network Hemovigilance Module in the United States affords an opportunity to compare results with those of other developed nations.

MATERIALS AND METHODS

Using data from national haemovigilance systems, reactions associated with red blood cell (RBC) transfusion and residual risks of transfusion-transmitted infectious diseases were assembled from 17 nations. Country-specific rates of adverse events were pooled using random-effects Poisson regression.

RESULTS

Febrile non-haemolytic and delayed serologic transfusion reactions were the most frequent adverse events reported after RBC transfusion, occurring in 26 patients per 100 000 RBC units and 25 patients per 100 000 RBC units administered, respectively. Rates of allergic, febrile non-haemolytic and delayed haemolytic transfusion reactions in the United States were significantly greater than the pooled rates from other countries. Frequencies of adverse events generated from the national haemovigilance programme in the United States were considerably lower than when obtained through active surveillance.

CONCLUSION

Haemovigilance reports of adverse events in the United States are comparable to, or greater than, reports from other developed countries. Rates generated from haemovigilance programmes are lower than those obtained through active surveillance. The lack of universal leucoreduction of RBC units may be a contributing factor to the higher rate of some adverse events in the United States.

Blood transfusion safety: A study of adverse reactions at the blood bank of a tertiary care center

BACKGROUND

An adverse transfusion reaction (ATR) is an unfavorable reaction to the transfused unit, the severity of which may be different among individuals depending upon the type of reaction and the patient's susceptibility. Transfusion reactions may be immediate or delayed type depending on the onset and immune or nonimmune type depending on the pathogenesis. A study was conducted to study the frequency of various transfusion reactions and the associated morbidity.

MATERIALS AND METHODS

All ATRs occurring over a period of 3 years at a tertiary care health center were studied in detail according to the institute's protocol.

RESULTS

Of 38,013 units of blood and components that had been issued, 101 (0.2%) cases had an ATR. The most common reaction was allergic - 34/101 (33.6%) followed by febrile - 26/101 (25.7%). Other reactions included transfusion-related acute lung injury in 6/101 (5.9%) cases, and immune reactions were seen in 19/101 (18.8%) cases.

CONCLUSION

Allergic and febrile reactions are most common and least harmful, but fatal reactions can also occur, and preventive measures must be taken to avoid such reactions.

How we approach a patient with symptoms of leukostasis requiring emergent leukocytapheresis

Hyperleukocytosis can induce leukostasis, which can lead to vascular obstructions (usually in the lungs and central nervous system), tumor lysis syndrome, and disseminated intravascular coagulation. Although it has not been conclusively shown to improve long-term outcome, leukocytapheresis may be used as part of the management of hyperleukocytosis with or without leukostasis to rapidly reduce the white blood cell (WBC) burden. Since leukocytapheresis only temporarily decreases the WBC count, early initiation of more definite therapy, such as hydroxyurea and/or chemotherapy, is essential. In this article, clinical assessment of the patient's clinical status to determine the need for leukocytapheresis as well as a general guideline for management of the technical aspects and complications of the procedure are discussed.