Prospective monitoring of plasma and platelet transfusions in a large teaching hospital results in significant cost reduction

Paediatric clinical decision support: Evaluation of a best practice alert for red blood cell transfusion

BACKGROUND AND OBJECTIVES

Providing red blood cell (RBC) transfusion to paediatric patients with a haemoglobin (Hb) level of <7 g/dL is the current best practice, but it is often difficult to ensure appropriateness of RBC transfusion on a health system level. Electronic health record (EHR) clinical decision support systems have been shown to be effective in encouraging providers to transfuse at appropriate Hb thresholds. We present our experience with an interruptive best practice alert (BPA) at a paediatric healthcare system.

MATERIALS AND METHODS

An interruptive BPA requiring physician response was implemented in our EHR (Epic Systems Corp., Verona, WI, USA) in 2018 based on Hb thresholds for inpatients. The threshold was initially <8 g/dL and later changed to <7 g/dL in 2019. We assessed total activations, number of RBC transfusions and hospital metrics through 2022 compared to the 2 years prior to implementation.

RESULTS

The BPA activated 6956 times over 4 years, slightly less than 5/day, and the success rate, with no RBC transfusions within 24 h of order attempt, was 14.5% (1012/6956). There was a downward trend in the number of total RBC transfusions and RBC transfusions per admission after implementation, non-significant (p = 0.41 and p = >0.99). The annual case mix index was similar over the years evaluated. The estimated cost savings based on acquisition costs for RBC units were 213,822 USD or about $51,891 per year.

CONCLUSION

BPA implementation led to sustained change in RBC transfusion towards best practice, and there were long-term savings in RBC expenditure.

Blood conservation strategies at United States hospitals during the COVID‐19 pandemic: Findings from a multi‐institutional analysis

Background

Due to the coronavirus disease 2019 (COVID‐19) pandemic, the transfusion medicine community has experienced unprecedented blood supply shortages since March 2020. As such, numerous changes to everyday practice have occurred with a specific emphasis on blood conservation. We sought to determine the strategies used to mitigate blood shortages and promote blood conservation during the pandemic.

Methods

An anonymous, 37‐question survey was developed using Research Electronic Data Capture and distributed via e‐mail to transfusion medicine specialists across the US obtained via publicly available databases.

Results

Amongst surveyed [41.1% response rate (51/124 institutions)], 98.0% experienced a product shortage, with the greatest number reporting red blood cell (RBC) shortages (92.0%). This led to 35.3% of institutions altering the composition and/or number of blood product suppliers, including a 100% increase in the number of institutions acquiring blood from organizations that connect hospital transfusion services with blood collection centers (e.g., Blood Buy) compared to before March 2020. Prospective triaging of blood products was the most common blood conservation strategy (68.1%), though 35.4% altered their RBC exchange or transfusion program for patients receiving chronic RBC transfusion/exchange. As a result of these changes, 78.6% of institutions reported that these changes resulted in a reduction in blood product usage, and 38.1% reported a decrease in product wastage.

Conclusions

Most hospitals experienced the effects of the supply shortage, and many of them implemented blood conserving measures. Conservation strategies were associated with decreased blood utilization and waste, and future studies could evaluate whether these changes persist.

Portuguese Consensus and Recommendations for Acquired Coagulopathic Bleeding Management (CCBM)

We aimed to determine how Portuguese physicians handle major bleeding. We also aim to establish global diagnostic and therapeutic recommendations to be followed in clinical practice by using a step-wise approach of evidence generation. This study followed a three-step process: a steering committee desk review, a Delphi technique, an expert panel meeting. A modified 3-round Delphi including 31 statements was performed. Questions were answered in a five-point Likert-type scale. Consensus threshold was established as a percentage of agreement among participants ≥90% in the first round, and ≥85% in the second and third rounds. The level of consensus achieved by panelists was discussed with the scientific committee (January-2020). Fifty-one physicians participated in the study (compliance rate >90%). Analyzing the three rounds, consensus was reached on 20 items (64.5%) in the first, 4/11 items (36.4%) in the second and 6/7 items (85.7%) in the third. One statement about administration of clotting factor concentrates for bleeding control did not reach consensus. A high level of consensus was reached toward the need for implementing Patient Blood Management strategies in Portuguese hospitals, reduce exposure to allogeneic blood components, to use goal directed therapies for acquired bleeding management, and the need for evaluating blood transfusion indirect costs. A final version with 12 recommendations was built, according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Our results provide critically appraised and updated evidence on bleeding coagulopathies management in Portugal. Additional studies, mainly about indirect costs of blood transfusion, are needed.

Activity-based cost of platelet transfusions in medical and surgical inpatients at a US hospital

BACKGROUND AND OBJECTIVES

Previous studies by the Cost of Blood Consensus Conference (COBCON) have used a comprehensive, standardized and generalizable activity-based costing (ABC) model to estimate the cost of red blood cell transfusions and plasma transfusion. The objective of this study was to determine the total cost of platelet transfusions in a real-world US hospital inpatient setting.

MATERIALS AND METHODS

This database analysis study retrospectively collected costs for all activities related to platelet transfusion in a single-acute care US teaching hospital in 2017. Costs were collected in a stepwise manner using a custom ABC model which mapped the technical, administrative and clinical processes involved in the transfusion of platelets.

RESULTS

For the 15 024 inpatients included in the analysis, 6335 (42·2%) were given a blood type and screen, and 941 (6·3%) received a transfusion of one or more blood products. A total of 333 platelet units were transfused in 131 patients (mean 2·54 units per patient): 211 (63·4%) units in medical inpatients and 122 (36·6%) in surgical inpatients. The total cost was $1359·99 per platelet unit, corresponding to $3457·06 per inpatient. Acquisition costs made up the largest proportion of the total cost (45·1%) followed by direct and indirect overheads (38·7%) and hospital processes costs (16·3%).

CONCLUSION

This is the first study to use an ABC costing model to determine the full cost of platelet transfusions within a US inpatient setting. This provides a useful reference point for comparisons with other transfusion products, and considerations for cost reduction.

Plasma Transfusion Practice in Adult Surgical Patients: Systematic Review of the Literature

Background

Plasma transfusions are most commonly used therapeutically for bleeding or prophylactically in non-bleeding patients prior to invasive procedures or surgery. Although plasma transfusions generally seem to decline, plasma usage for indications that lack evidence of efficacy prevail.

Summary

There is wide international, interinstitutional, and interindividual variance regarding the compliance with guidelines based on published references, supported by appropriate testing. There is furthermore a profound lack of evidence from randomized controlled trials comparing the effect of plasma transfusion with that of other therapeutic interventions for most indications, including massive bleeding. The expected benefit of a plasma transfusion needs to be balanced carefully against the associated risk of adverse events. In light of the heterogeneous nature of bleeding conditions and their rapid evolvement over time, fibrinogen and factor concentrate therapy, directed at specific phases of coagulation identified by alternative laboratory assays, may offer advantages over conventional blood product ratio-driven resuscitation. However, their outcome benefit has not been demonstrated in well-powered prospective trials. This systematic review will detail the current evidence base for plasma transfusion in adult surgical patients.

Antimicrobial blue light for decontamination of platelets during storage

Platelet (PLT) storage is currently limited to 5 days in clinics in the United States, in part, due to an increasing risk for microbial contamination over time. In light of well-documented antimicrobial activity of blue light (405-470 nm), we investigated potentials to decontaminate microbes during PLT storage by antimicrobial blue light (aBL). We found that PLTs produced no detectable levels of porphyrins or their derivatives, the chromophores that specifically absorb blue light, in marked contrast to microbes that generated porphyrins abundantly. The difference formed a basis with which aBL selectively inactivated contaminated microbes prior to and during the storage, without incurring any harm to PLTs. In accordance with this, when contamination with representative microbes was simulated in PLT concentrates supplemented with 65% of PLT additive solution in a standard storage bag, all "contaminated" microbes tested were completely inactivated after exposure of the bag to 405 nm aBL at 75 J/cm2 only once. While killing microbes efficiently, this dose of aBL irradiation exerted no adverse effects on the viability, activation or aggregation of PLTs ex vivo and could be used repeatedly during PLT storage. PLT survival in vivo was also unaltered by aBL irradiation after infusion of aBL-irradiated mouse PLTs into mice. The study provides proof-of-concept evidence for a potential of aBL to decontaminate PLTs during storage.

Is Platelet Expiring Out of Date? A Systematic Review

Current platelet concentrates are perishable blood products with short shelf lives. Combined with often unpredictable demand, this results in platelet inventory management problems, manifested by high rates of outdating frequently reported at 10% to 20%, and sometimes inadequate clinical supply. The objective of this study was to critically review the published methodologies on measures to reduce platelet outdating rates, in order to determine how platelet outdating and availability can be improved. We performed a systematic review of journal articles published in English to May 2019 identified from MEDLINE, with reported methods to improve platelet inventory outdating rates and availability. The complexity of each methodology was scored based on whether a typical blood bank manager could design, implement and run a platelet outdating program based on the methodology. Twenty-four relevant citations were found-these included 8 citations employing operational research (OR) methodologies, 7 evaluation/best practice, 6 simulation and 3 forecasting. Over half the included studies have been published within the last decade. The citations reporting the lowest predicted outdating were also the most complex methods. Overall predicted outdating and shortages were less than 4% based on the available data. In conclusion, we found that research interest in platelet inventory management problems has increased in line with platelet demand and methods to assist in reducing outdating rates without increased shortages have been available now for 4 decades; high rates of platelet outdating do however continue to be reported around the world. Developments in platelet preparation and storage, and other new approaches, may assist in addressing this problem.

Potentials for prolonging shelf-life of platelets by near infrared low-level light

Platelets are uniquely stored at room temperature, during which they gradually loss their quality owing to deteriorating functions of mitochondria over time. Given the well-documented beneficial effect of near infrared low-level light (LLL) on mitochondrial functions, we explored a potential for LLL to protect mitochondrial function and extend the shelf-life of platelets beyond the current 5 days. We found that exposure of a platelet-containing storage bag to 830 nm light-emitting diode (LED) light at 0.5 J/cm² prior to storage could significantly retain a pH value and viability of the platelets stored for 8 days with improved quality compared to those stored similarly for 5 days in controls. The LLL inhibited reactive oxygen species (ROS) and lactate production, while sustaining ATP synthesis and mitochondrial membrane potential and morphology in the stored platelets. It also sustained aggregation capacity and in vivo survival of stored platelets, concomitant with no significant activation, as suggested by similar CD62p expression and enhanced agonist-induced aggregation and recovery following infusion in the presence compared to absence of LLL treatment. This simple, additive-free, cost-effective, noninvasive approach can be readily incorporated into the current platelet storage system to potentially improve quality of stored platelets.

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.

Real-Time Clinical Decision Support Decreases Inappropriate Plasma Transfusion

OBJECTIVES

To curtail inappropriate plasma transfusions, we instituted clinical decision support as an alert upon order entry if the patient's recent international normalized ratio (INR) was 1.7 or less.

METHODS

The alert was suppressed for massive transfusion and within operative or apheresis settings. The plasma order was automatically removed upon alert acceptance while clinical exception reasons allowed for continued transfusion. Alert impact was studied comparing a 7-month control period with a 4-month intervention period.

RESULTS

Monthly plasma utilization decreased 17.4%, from a mean ± SD of 3.40 ± 0.48 to 2.82 ± 0.6 plasma units per hundred patient days (95% confidence interval [CI] of difference, -0.1 to 1.3). Plasma transfused below an INR of 1.7 or less decreased from 47.6% to 41.6% (P = .0002; odds ratio, 0.78; 95% CI, 0.69-0.89). The alert recommendation was accepted 33% of the time while clinical exceptions were chosen in the remaining cases (active bleeding, 31%; other clinical indication, 33%; and apheresis, 2%). Alert acceptance rate varied significantly among different provider specialties.

CONCLUSIONS

Clinical decision support can help curtail inappropriate plasma use but needs to be part of a comprehensive strategy including audit and feedback for comprehensive, long-term changes.

How do we reduce plasma transfusion in Rhode Island?

BACKGROUND

Plasma transfusions are given to patients with coagulopathy, either prophylactically, before an invasive procedure; or therapeutically, in the presence of active bleeding; and as an exchange fluid in therapeutic plasma exchange for disorders such as thrombotic thrombocytopenic purpura. There is consensus that many prophylactic plasma transfusions are non-efficacious, and the misdiagnosis of thrombotic thrombocytopenic purpura results in unnecessary therapeutic plasma exchange.

STUDY DESIGN AND METHODS

Beginning in 2001, programs to reduce plasma transfusion in the three major teaching hospitals in Rhode Island were initiated. The programs evolved through the establishment of guidelines, education for key prescribers of plasma, screening of plasma prescriptions, and engagement of individual prescribing physicians for out-of-guidelines prescriptions with modification or cancellation. Establishment of an in-house ADAMTS13 (ADAM metallopeptidase with thrombospondin type 1, motif 13) assay in 2013 was used to prevent therapeutic plasma exchange in patients with non-thrombotic thrombocytopenic purpura microangiopathy. Transfusion service data were gathered at the hospital level regarding blood component use, hospital data for discharges, inpatient mortality, and mean case-mix index, and, at the state level, for units of plasma shipped from the community blood center to in-state hospitals.

RESULTS

Between 2006 and 2016, a reduction in plasma use from 11,805 to 2677 units (a 77% decrease) was observed in the three hospitals and was mirrored in the state as a whole. This decline was not associated with any increase in red blood cell transfusion. Inpatient mortality either declined or was unchanged.

CONCLUSION

An active program focused on education and interdiction can achieve a large decrease in plasma transfusions without evidence of patient harm.

Evaluation of RBC Transfusion Practice in Adult ICUs and the Effect of Restrictive Transfusion Protocols on Routine Care

OBJECTIVE

Research supports the efficacy and safety of restrictive transfusion protocols to reduce avoidable RBC transfusions, but evidence of their effectiveness in practice is limited. This study assessed whether admission to an ICU with an restrictive transfusion protocol reduces the likelihood of transfusion for adult patients.

DESIGN

Observational study using data from the multicenter, cohort Critical Illness Outcomes Study. Patient-level analyses were conducted with RBC transfusion on day of enrollment as the outcome and admission to an ICU with a restrictive transfusion protocol as the exposure of interest. Covariates included demographics, hospital course (e.g., lowest hematocrit, blood loss), severity of illness (e.g., Sequential Organ Failure Assessment score), interventions (e.g., sedation/analgesia), and ICU characteristics (e.g., size). Multivariable logistic regression modeling assessed the independent effects of restrictive transfusion protocols on transfusions.

SETTING

Fifty-nine U.S. ICUs.

PATIENTS

A total of 6,027 adult ICU patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 59 study ICUs, 24 had an restrictive transfusion protocol; 2,510 patients (41.6%) were in an ICU with an restrictive transfusion protocol. The frequency of RBC transfusion among patients with severe (hematocrit, < 21%), moderate (hematocrit, 21-30%), and mild (hematocrit, > 30%) anemia in restrictive transfusion protocol ICUs was 67%, 19%, and 4%, respectively, compared with 60%, 14%, and 2% for those in ICUs without an restrictive transfusion protocol. Only 27% of transfusions were associated with a hematocrit less than 21%. Adjusting for confounding factors, restrictive transfusion protocols independently reduced the odds of transfusion in moderate anemia with an odds ratio of 0.59 (95% CI, 0.36-0.96) while demonstrating no effect in mild (p = 0.93) or severe (p = 0.52) anemia.

CONCLUSIONS

In this sample of ICU patients, transfusions often occurred outside evidence-based guidelines, but admission to an ICU with an restrictive transfusion protocol did reduce the risk of transfusion in moderately anemic patients controlling for patient and ICU factors. This study supports the effectiveness of restrictive transfusion protocols for influencing transfusions in clinical practice.

Patient blood management: is it worth to be employed?

PURPOSE OF REVIEW

In recent years, the view changed from 'product orientated' to 'patient orientated' and a new concept, named 'patient blood management' (PBM), was created with the aim to improve patient care and safety. However, changing long lasting work practice is more than challenging but the outcomes of several recently published studies confirm the concept and warrant the effort. This review will exemplify the need of patient centered treatments and highlight recent findings in the field of PBM.

RECENT FINDINGS

Anemia is the biggest predictor for red blood cell transfusion that may by itself be associated with adverse outcome. PBM is a multiprofessional and multidisciplinary composition addressing a patient-centered prevention and treatment of both preoperative and hospital-acquired anemia. Thereby, red blood cell utilization can be reduced and patient perioperative outcome improved.

SUMMARY

During recent years, a tremendous movement has been observed in respect of patient safety and patient blood use. However, the majority of hospitals hazard with the implementation of PBM practice mostly because the awareness about recent findings and current recommendations regarding PBM is lacking.

Is there a "magic" hemoglobin number? Clinical decision support promoting restrictive blood transfusion practices

Blood transfusion has been identified as one of the most frequently performed therapeutic procedures, with a significant percentage of transfusions identified to be inappropriate. Recent key clinical trials in adults have provided Level 1 evidence to support restrictive red blood cell (RBC) transfusion practices. However, some advocates have attempted to identify a "correct" Hb threshold for RBC transfusion; whereas others assert that management of anemia, including transfusion decisions, must take into account clinical patient variables, rather than simply one diagnostic laboratory test. The heterogeneity of guidelines for blood transfusion by a number of medical societies reflects this controversy. Clinical decision support (CDS) uses a Hb threshold number in a smart Best Practices Alert (BPA) upon physician order, to trigger a concurrent utilization self-review for whether blood transfusion therapy is appropriate. This review summarizes Level 1 evidence in seven key clinical trials in adults that support restrictive transfusion practices, along strategies made possible by CDS that have demonstrated value in improving blood utilization by promoting restrictive transfusion practices.

Evaluation of the appropriateness of frozen plasma usage after introduction of prothrombin complex concentrates: a retrospective study

BACKGROUND

Prothrombin complex concentrates (PCCs) can be used instead of frozen plasma (FP) transfusion to reverse the effect of warfarin. Audits have demonstrated over usage of FP transfusions even before the introduction of PCC. The objective of this study was to determine the appropriateness of current FP transfusion practice in the current era since the introduction of PCCs.

METHODS

A retrospective cohort study of consecutive patients receiving FP over 3 months was carried out. Each episode of FP use over a 24-h period was adjudicated independently by two reviewers as appropriate (consistent with Canadian/AABB guidelines), appropriate but inconsistent with guidelines or inappropriate. Discrepancies were resolved by a third reviewer. Use of FP to reverse warfarin was considered inappropriate. FP usage from previous years was assessed as baseline.

RESULTS

During the study period, 111 FP transfusions were administered. 74.8% of FP usage occurred in the ICU. The proportion of FP transfusions that were deemed appropriate, inconsistent yet appropriate or inappropriate were 33/89 (37.1%), 16/89 (18.0%) and 40/89 (44.9%), respectively, when use of FP for therapeutic plasma exchange was excluded. The most common reasons for inappropriate use were the absence of bleeding with an increased INR or warfarin reversal.

CONCLUSION

Our study is the first to audit FP transfusions in the post-PCC era in Canada. FP usage remains inappropriately high in INR prolongation without another indication or to reverse warfarin. Targeted interventions to reduce FP usage in the future should focus on the ICU and on education about warfarin reversal.

The next chapter in patient blood management: real-time clinical decision support

OBJECTIVES

Blood transfusion was identified by the American Medical Association as one of the top five most frequently overused therapies. Utilization review has been required by accreditation agencies, but retrospective review has been ineffective due to labor-intense resources applied to only a sampling of transfusion events. Electronic medical records have allowed clinical decision support (CDS) to occur via a best practices alert at the critical decision point concurrently with physician order entry.

METHODS

We review emerging strategies for improving blood utilization.

RESULTS

Implementation of CDS at our institution decreased the percentage of transfusions in patients with a hemoglobin level of more than 8 g/dL from 60% to less than 30%. Annual RBC transfusions were reduced by 24%, despite concurrent increases in patient discharge volumes and case mix complexity. This resulted in acquisition costs savings (direct blood product purchase costs) of $6.4 million over 4 years.

CONCLUSIONS

We have been able to significantly reduce inappropriate blood transfusions and related costs through an educational initiative coupled with real-time CDS. In deriving increased value out of health care, CDS can be applied to a number of overuse measures in laboratory testing, radiology, and therapy such as antibiotics, as outlined by the American Board of Internal Medicine's Choosing Wisely campaign.

Effective reduction of blood product use in a community teaching hospital: when less is more

BACKGROUND

The increased morbidity and mortality associated with liberal blood product usage have been convincingly demonstrated. The clinical problems they pose have prompted development of more restrictive evidence-based transfusion criteria. Education alone has a limited impact on the adoption of these criteria into practice. New York Methodist Hospital undertook a proactive approach to reduce unnecessary transfusions.

METHOD

In November 2008, an interventional monitoring program to ensure adherence to transfusion criteria for packed red blood cells (PRBC), platelets, fresh frozen plasma (FFP), and cryoprecipitate transfusions was started. Blood bank technologists routinely monitored transfusion requests against a list of established criteria and experienced clinicians reviewed and adjudicated transfusion requests when the blood bank technologist's action was appealed.

RESULTS

Transfusion usage decreased sharply in Year 1 (November 2008-October 2009) and continued to decrease in Year 2 (November 2009-October 2010). PRBC use decreased by 30.1% and 37.7%, with a 47.6% decrease in multi-unit transfusions; platelet use decreased by 24.3% and 41.2%; fresh frozen plasma use decreased by 41.8% and 31.1%; and cryoprecipitate use decreased by 38.7% and 56.1% during monitoring Years 1 and 2, respectively. Decreases occurred despite a 4.0% increase in hospital admissions during the monitoring years. The decreased blood product usage was accompanied by 28.6% reduction in complications. A 26.1% decrease in blood product requests from Year 1 to Year 2 suggested a practice change by the ordering physicians themselves. The total cost of blood products decreased by $2,235,676.

CONCLUSION

We established a successful method to reduce transfusions of all blood products using strict adherence to evidence-based criteria and continuous monitoring. Our model translates into improved patient safety by decreasing the number of unnecessary transfusions. This also led to a significant reduction in hospital expenses.

Increased platelet storage time is associated with mitochondrial dysfunction and impaired platelet function

BACKGROUND

Hemorrhagic shock is a leading cause of death following severe trauma, and platelet transfusions are frequently necessary to achieve hemostasis. Platelets, however, require special storage conditions, and storage time has been associated with loss of platelet quality. We hypothesized that standard storage conditions have a deleterious effect on platelet mitochondrial function and platelet activation.

MATERIALS AND METHODS

Platelet donations were collected from healthy donors (n = 5) and stored in gas-permeable collection bags according to American Association of Blood Bank recommendations. Platelet units were sampled from day of collection (day 0) until day 7. High-resolution respirometry was used to assess baseline mitochondrial respiration, maximal oxygen utilization, and individual mitochondrial complex-dependent respiration. Fluorescence-activated cell sorting was performed to analyze mitochondrial content, mitochondrial reactive oxygen species, the expression of P-selectin (both before and after challenge with thrombin receptor-activating peptide), and apoptosis. Data were analyzed using analysis of variance and Pearson correlation (P < 0.05 significant).

RESULTS

Mitochondrial respiration decreased significantly in platelets stored longer than 2 d (P < 0.05). Platelets also demonstrated a persistent decrease in response to stimulation with thrombin receptor-activating peptide by the third day of storage (P < 0.05) as well as an increase in mitochondrial reactive oxygen species and apoptosis (P < 0.05). Mitochondrial respiration significantly correlated with platelet capacity to activate (r = 0.8, P < 0.05).

CONCLUSIONS

Platelet mitochondrial respiratory function and activation response decrease significantly in platelets stored for 3 d or more. Because platelet transfusions almost universally occur between the third and fifth day of storage, our findings may have significant clinical importance and warrant further in vivo analysis.

How we manage AB plasma inventory in the blood center and transfusion service

The growing use of group AB plasma in the United States in recent years poses unique challenges to blood centers and transfusion services. Blood centers must collect sufficient plasma components from a limited pool of group AB donors while taking steps to improve transfusion safety that further restricts the available supply. Transfusion services, on the other hand, must use the finite resource in the most conscientious and medically appropriate manner. Recently, many investigations have challenged long-held beliefs about transfusion practice and appropriate indications for blood components across a variety of specialties. Balancing supply and demand of group AB plasma requires collaboration between blood suppliers and transfusion services, and opportunities for improvement exist on both sides of the equation.

Hemorrhage and Transfusions in the Surgical Patient

Hemorrhage is the leading cause of intraoperative deaths. Many cardiovascular and hepatobiliary procedures result in massive hemorrhage and postpartum hemorrhage events in labor and delivery place the patient at a high risk for mortality. Gastrointestinal bleeding from diverticulosis, varices, and ulcer disease can result in significant blood loss requiring massive transfusion and resuscitation from hemorrhagic shock. Timely and effective transfusion of blood products is of critical in these scenarios. The frequency in which blood component products are transfused in surgical patients begs for a greater understanding of them. The aim of this chapter is to provide clinicians with a discussion of the current literature on the various blood component products, their indications, and unique hemostatic conditions in the surgical patient. While the majority of data concerning optimal management of acquired coagulopathy and hemorrhagic shock resuscitation is based on trauma patients, many of the principles can and should be applied to the surgical patient (or likely any patient) with profound hemorrhage.

The risk of postpolypectomy bleeding during colonoscopy in patients with early liver cirrhosis

BACKGROUND

Colonoscopists are often hesitant to perform endoscopic polypectomy in patients with liver cirrhosis (LC) because of the risk for postpolypectomy bleeding (PPB). However, little is known about the risk of PPB in these patients.

METHODS

We performed a retrospective study of patients with early LC who underwent colonoscopic polypectomy at a single center between September 2006 and May 2011. We investigated the incidence of immediate PPB (IPPB) and delayed PPB (DPPB) in these patients. In addition, we investigated which LC-related and polyp-related factors were associated with IPPB.

RESULTS

Thirty patients with LC were included in our study, and 29 (96.7 %) of them were classified in Child-Pugh class A or B. The mean prothrombin time was 1.27 ± 0.23, and the mean platelet count was 136.77 ± 106.49 × 10(3)/L. A total of 66 polyps in 30 patients were removed. In terms of IPPB, only 2 (3.03 %) of the 66 removed polyps presented with mild oozing and were controlled by hemostatic procedures using hemoclips. DPPB did not occur in any of the patients in the IPPB or the non-IPPB group. Although the IPPB polyp group was too small to detect statistical significance, the IPPB polyps were larger than the non-IPPB polyps (22.5 ± 10.61 vs. 7.22 ± 3.01 mm), and the gross morphology of both IPPB polyps was the pedunculated type. However, LC-related variables such as platelet counts and Child-Pugh scores did not significantly differ between the IPPB and non-IPPB groups.

CONCLUSIONS

In patients with early LC, the risk of postpolypectomy bleeding was acceptably low and there was no case with DPPB. Therefore, polypectomy can be performed with caution. IPPB was associated with the size and the gross morphology of the polyps. However, LC-related variables in patients with early LC did not impact IPPB.

Platelet usage trends in a tertiary care hospital - Could it be less and less expensive?

Major bleeding is a life threatening complication of severe thrombocytopenia. The aim of this study was to find out the indications and the threshold for platelet transfusions in the pediatric patients of our hospital throughout 1 year. Records of the hospital's blood bank and the files of the patients were retrospectively reviewed. One hundred and four patients, between ages 0-18 years received 378 platelet units. Pretransfusion platelet counts were found to be significantly lower in hematology-oncology groups compared to other clinics (p<0.05). Single donor apheresis was found to be the major source of platelets in hematology (80.8%, n=147) and oncology (86.5%, n=45) clinics. There is a tendency for using apheresis products without proven superiority compared to platelet concentrates in terms of efficacy. This practice can be abandoned by continuous education.