Prevention of syncopal-type reactions after whole blood donation: a cluster-randomized trial assessing hydration and muscle tension exercise

Development and validation of a scoring system to predict vasovagal reaction upon whole-blood donation

BACKGROUND AND OBJECTIVES

Risk factors for vasovagal reaction (VVR) have been extensively studied. With knowledge of the relative importance of these risk factors for VVR, collection staff could take care of blood donors from the same standpoint, leading to improved donor safety. We therefore developed a scoring system to predict VVR, which incorporates registration information.

MATERIALS AND METHODS

Pre-syncopal and syncopal symptoms, as well as on- and off-site reactions, are included in this analysis as VVR. We defined the donor status as follows: first-time donors, repeat donors with no history of reaction and repeat donors with a history of reaction. We prepared two datasets: whole-blood donations at a blood donation site in Tokyo between January 2019 and December 2019 were included in training data (n = 361,114), and whole-blood donations between January 2020 and August 2020 were included in testing data (n = 216,211).

RESULTS

The most important variable was the donor status, followed by age, estimated blood volume and height. We integrated them into a scoring system. Training and testing datasets were combined (n = 577,325), and VVR rates in groups with scores of 0, 1, 2, 3, 4 and 5 or more were 0.09% (95% CI: 0.081%-0.10%), 0.33% (95% CI: 0.31%-0.36%), 0.87% (95% CI: 0.78%-0.96%), 1.17% (95% CI: 1.05%-1.30%), 2.15% (95% CI: 1.98%-2.32%) and 3.11% (95% CI: 2.90%-3.34%), respectively.

CONCLUSION

The scoring system enables staff to significantly predict VVR and may help them to identify donors at increased risk of experiencing syncope, thereby mitigating the negative impact of VVR on donor safety and return by paying close attention to high-risk donors.

Prevention strategies for vasovagal reaction in whole blood donors: A quadri-armed randomised control trial

INTRODUCTION

Vasovagal reaction (VVR) is a frequently encountered generalised donor adverse reaction, associated with donor deterrence towards future donation. Several mitigation strategies for prevention of VVR were tried but still not standardised. This quadri-armed randomised study evaluated the utility of water ingestion, applied muscle tension (AMT) and combination of both in preventing the VVR among blood donors.

METHODS

A quadri-armed randomised controlled trial was performed on 4320 whole blood donors. Blood donors of 18-65 years of age were randomised into four groups based on the interventions performed i.e., control with no intervention (Group 1, n = 1081), water ingestion (Group 2, n = 1082), AMT (Group 3, n = 1070) and combined intervention (Group 4, n = 1087). VVR during and immediately after blood donation were observed along with assessment of risk factors in blood donors and the effectiveness of interventions were analysed.

RESULTS

The incidence of VVR observed 1.6% in our study, with the highest occurrence in the control group (2.5%) and the lowest in the combined intervention group (0.9%). Multivariable logistic regression revealed that the control group donors faced a 1.38-fold greater risk of VVR compared to those receiving interventions (OR: 1.38, 95% CI: 1.10-1.75). Other risk factors included younger age (OR: 1.5, 95% CI: 1.05-2.17), first-time donation (OR: 5.7, 95% CI: 1.66-5.74), prior history of VVR (OR: 2.5, 95% CI: 10.4-101.52).

DISCUSSION/CONCLUSION

The combined approach of water ingestion and AMT proved significantly more effective in VVR prevention compared to individual interventions.

Orthostatic intolerance after acute mild hypovolemia: incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study

PURPOSE

Early postoperative mobilization can be hindered by orthostatic intolerance (OI). Postoperative OI has multifactorial pathogenesis, possibly involving both postoperative hypovolemia and autonomic dysfunction. We aimed to investigate the effect of mild acute blood loss from blood donation simulating postoperative hypovolemia, on both autonomic function and OI, thus eliminating confounding perioperative factors such as inflammation, residual anesthesia, pain, and opioids.

METHODS

This prospective observational cohort study included 26 blood donors. Continuous electrocardiogram data were collected during mobilization and night sleep, both before and after blood donation. A Valsalva maneuver and a standardized mobilization procedure were performed immediately before and after blood donation, during which cardiovascular and tissue oxygenation variables were continuously measured by LiDCOrapid™ and Massimo Root™, respectively. The incidence of OI, hemodynamic responses during mobilization and Valsalva maneuver, as well as heart rate variability (HRV) responses during mobilization and sleep were compared before and 15 min after blood donation.

RESULTS

Prior to blood donation, no donors experienced OI during mobilization. After blood donation, 6/26 (23%; 95% CI, 9 to 44) donors experienced at least one OI symptom. Three out of 26 donors (12%; 95% CI, 2 to 30) terminated the mobilization procedure prematurely because of severe OI symptoms. Cardiovascular and cerebral tissue oxygenation responses were reduced in patients with severe OI. After blood loss, HRV indices of total autonomic power remained unchanged but increased sympathetic and decreased parasympathetic outflow was observed during mobilization, but also during sleep, indicating a prolonged autonomic effect of hypovolemia.

CONCLUSION

We describe a specific hypovolemic component of postoperative OI, independent of postoperative autonomic dysfunction, inflammation, opioids, and pain.

STUDY REGISTRATION

ClinicalTrials.gov (NCT04499664); registered 5 August 2020.

Evaluation of interventions to prevent vasovagal reactions among whole blood donors: rationale and design of a large cluster randomised trial

BACKGROUND

Vasovagal reactions (VVRs) are the most common acute complications of blood donation. Responsible for substantial morbidity, they also reduce the likelihood of repeated donations and are disruptive and costly for blood services. Although blood establishments worldwide have adopted different strategies to prevent VVRs (including water loading and applied muscle tension [AMT]), robust evidence is limited. The Strategies to Improve Donor Experiences (STRIDES) trial aims to reliably assess the impact of four different interventions to prevent VVRs among blood donors.

METHODS

STRIDES is a cluster-randomised cross-over/stepped-wedge factorial trial of four interventions to reduce VVRs involving about 1.4 million whole blood donors enrolled from all 73 blood donation sites (mobile teams and donor centres) of National Health Service Blood and Transplant (NHSBT) in England. Each site ("cluster") has been randomly allocated to receive one or more interventions during a 36-month period, using principles of cross-over, stepped-wedge and factorial trial design to assign the sequence of interventions. Each of the four interventions is compared to NHSBT's current practices: (i) 500-ml isotonic drink before donation (vs current 500-ml plain water); (ii) 3-min rest on donation chair after donation (vs current 2 min); (iii) new modified AMT (vs current practice of AMT); and (iv) psychosocial intervention using preparatory materials (vs current practice of nothing). The primary outcome is the number of in-session VVRs with loss of consciousness (i.e. episodes involving loss of consciousness of any duration, with or without additional complications). Secondary outcomes include all in-session VVRs (i.e. with and without loss of consciousness), all delayed VVRs (i.e. those occurring after leaving the venue) and any in-session non-VVR adverse events or reactions.

DISCUSSION

The STRIDES trial should yield novel information about interventions, singly and in combination, for the prevention of VVRs, with the aim of generating policy-shaping evidence to help inform blood services to improve donor health, donor experience, and service efficiency.

TRIAL REGISTRATION

ISRCTN: 10412338. Registration date: October 24, 2019.

Predicting Vasovagal Reactions to Needles from Facial Action Units

BACKGROUND

Merely the sight of needles can cause extreme emotional and physical (vasovagal) reactions (VVRs). However, needle fear and VVRs are not easy to measure nor prevent as they are automatic and difficult to self-report. This study aims to investigate whether a blood donors' unconscious facial microexpressions in the waiting room, prior to actual blood donation, can be used to predict who will experience a VVR later, during the donation.

METHODS

The presence and intensity of 17 facial action units were extracted from video recordings of 227 blood donors and were used to classify low and high VVR levels using machine-learning algorithms. We included three groups of blood donors as follows: (1) a control group, who had never experienced a VVR in the past (n = 81); (2) a 'sensitive' group, who experienced a VVR at their last donation (n = 51); and (3) new donors, who are at increased risk of experiencing a VVR (n = 95).

RESULTS

The model performed very well, with an F1 (=the weighted average of precision and recall) score of 0.82. The most predictive feature was the intensity of facial action units in the eye regions.

CONCLUSIONS

To our knowledge, this study is the first to demonstrate that it is possible to predict who will experience a vasovagal response during blood donation through facial microexpression analyses prior to donation.

Pre-donation water and salty snacks to prevent vasovagal reactions among blood donors

BACKGROUND

Minimizing the risk of vasovagal reactions (VVRs) can prevent donor harms and improve donor return. We report the results of a program to reduce VVR rates.

STUDY DESIGN AND METHODS

The program was implemented on June 11, 2017 and consisted in drinking water and eating a salty snack before donating blood, plasma, or platelets. All donations made during the "pre-program period" (October 11, 2015-June 10, 2017) and "post-program period" (June 11, 2017-May 11, 2019) were included. Study outcomes comprised VVRs (any severity) and syncopal VVRs, whether employee- or donor-reported. An interrupted time series (ITS) analysis proxied causality based on the "pre-program trend," the "immediate trend" (i.e., immediately before versus after the program), and the "post-program trend". The relative risk (RR) of VVR (along with confidence intervals [CIs]) was reported, overall and stratified by subgroups based on age, sex, donor type (i.e., first-time versus repeat), and donation type (i.e., whole blood versus apheresis).

RESULTS

The monthly VVR rate (any severity) dropped from 4.6% in the pre-program period to 4.3% in the post-program period, and never reached its pre-program level. The ITS analysis revealed a statistically significant and increasing pre-program trend (RR [95% CI] = 1.011 [1.002-1.020]), a statistically significant and decreasing immediate trend (RR [95% CI] = 0.848 [0.743-0.969]), and a non-statistically-significant and stable post-program trend (RR [95% CI] = 0.999 [0.993-1.006]). Similar trends were observed for nearly all high- and low-risk subgroups. No statistically significant trend was observed for syncopal VVRs.

DISCUSSION

These results suggest that the herein-described program durably reduced the incidence of VVRs (any severity) by ~15%.

Effects of Performing Applied Muscle Tension during Recovery after Phlebotomy in Young, First-Time Donors: A Pilot Study

Vasovagal reaction (VVR) compromises donor safety and reduces the subsequent return rates. Performing applied muscle tension (AMT) during phlebotomy may reduce the incidence of VVR. However, the effectiveness of performing AMT after phlebotomy to reduce delayed VVR remains unclear. With ethics approval, 12 young, first-time donors (YFTD) were recruited to study the effects on stroke volume (SV), cardiac output (CO) and systemic vascular resistance (SVR) while performing AMT from needle insertion to end of recovery. Measurements from 12 matched control YFTD were used for comparison. Pre-donation anxiety and VVR severity were assessed. Compared to controls, donors who performed AMT had higher SV (Control: 57 mL vs. AMT: 69 mL, p = 0.045), higher CO (Control: 3.7 L·min⁻¹ vs. AMT: 5.2 L·min⁻¹, p = 0.006) and lower SVR (Control: 1962 dyn·s·cm⁻⁵ vs. AMT: 1569 dyn·s·cm⁻⁵, p = 0.032) during mid-phlebotomy. During recovery, the AMT group retained higher SV, higher CO and lower SVR than the control, but not reaching statistical significance. Practicing AMT during recovery resulted in sustained haemodynamic improvements beyond the donation period, despite the reduction in delayed VVR was insignificant compared to the control group. A larger sample size is needed to validate the effectiveness of performing AMT after donation to mitigate delayed VVR.

An intervention study for the prevention of vasovagal reactions and evaluating donors' experience: Analysis of donors' return for subsequent donation

BACKGROUND AND OBJECTIVES

The EPISoDe (Experience Success in Donation) study investigated the effect of interventions on self-reported vasovagal reactions (VVRs) in first-time and novice (second to fourth donation) whole blood donors aged ≤30 years, demonstrating a 23% reduction of VVR from water drinking shortly before donation in the novice donors. Because donation experience and complications affect donor retention, we analysed intervention group donors' return for subsequent donation, a predefined secondary outcome.

MATERIALS AND METHODS

The interventions were as follows: 330 ml water, 500 ml water, ball squeezing before phlebotomy (placebo) and a control group. All donors received an online questionnaire about their experience within a week after donation. In the Netherlands, eligible donors are invited at least yearly depending on hospitals' needs. We analysed attendances within 421 days through return percentages and binomial logistic regression.

RESULTS

Of the 8300 EPISoDe participants, 6538 (78.8%) returned within 421 days. Return did not differ between the two water groups, whereas odds for return were significantly higher in both water and placebo intervention donors compared to the control group (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.00-1.29 and 1.22, 1.05-1.43, respectively) after adjustment for occurrence of VVR, unsuccessful collection, gender and donation history. Staff-recorded or self-reported VVR at index donation was associated with reduced odds for return (OR 0.47, 95% CI 0.37-0.60 and OR 0.53, 95% CI 0.46-0.61, respectively).

CONCLUSION

In this cohort of younger inexperienced blood donors, 78.8% returned for subsequent donation. Donors who received an active study intervention, either water or placebo, were more likely to return than control group donors.

Implementation of measures to reduce vasovagal reactions: Donor participation and results

BACKGROUND

There are several strategies to reduce donor reactions. We report donor participation and reaction rates before and after implementing multiple measures at Canadian Blood Services.

STUDY DESIGN AND METHODS

We introduced a structured program of 500 mL of water and a salty snack pre-donation and applied muscle tension (AMT) during donation. Donors were not deferred for out of range blood pressure (BP); however, BP was measured in first time donors. Time on the donation chair post-donation was decreased from 5 to 2 min for repeat donors. We assessed participation rates using our quarterly survey of 10,000 recent donors. We extracted vasovagal reactions with loss of consciousness (LOC) from our operational database and compared pre-implementation (Oct 12,018-March 31,2019) and post-implementation (Oct 12,019-March 31,2020) periods.

RESULTS

Survey response rates varied from 11% to 16%. The percentage of donors who drank the water and ate the salty snack increased from 58% to 82% and 44% to 70% over 4 quarters; those performing AMT increased from 24% to 41%. Reactions decreased from 19.07 per 10,000 (744 reactions in 390,123 donations) to 14.04 per 10,000 (537 in 382,382 donations) (p < .0001). No first-time donors with high BP (n = 684) but 5 with low BP (n = 718) had reactions, CI were very large.

CONCLUSIONS

Achieving optimal participation was challenging. After implementation of a donor wellness initiative based on best practice, rates of vasovagal reactions with LOC decreased by 25%. A larger dataset is necessary to assess the safety contribution of BP deferrals when other mitigation measures are in place.

Blood collection failures from a blood establishment perspective

OBJECTIVES

The objective of this study was to show experience of the Croatian Institute of Transfusion Medicine in monitoring and analysing collection failures caused by the venepuncture technique or occurred as a result of adverse reactions and complications experienced by donors during donation.

BACKGROUND

Collection failures represent one of the leading nonconformities in blood establishments. Apart from being a negative motivating factor for blood donors, they also affect the blood components supply and have a negative financial impact.

METHODS

Nonconformity records referring to collection failures were analysed retrospectively over a 6-year period (2013-2018) with regard to their frequency, causes, donor characteristics (age, gender, number of donations), place of occurrence (blood establishment, mobile sessions) and trends during the analysed period.

RESULTS

A total of 5166 collection failures out of 618 251 donations (0.84%) were recorded during the analysed period. The leading cause was haematoma at puncture site (1676, i.e., 32.4%). Collection failures which are primarily attributed to the venepuncture technique or vein selection accounted for 91% of all cases, whereas collection failures which occurred as a result of discontinued punctures due to adverse reactions in donors accounted for 9% of all cases. A much higher frequency of all collection failure types was recorded in female donors, whereas younger donors experienced adverse reactions more frequently (median age of 24).

CONCLUSION

The analysis and monitoring frequency of collection failures play an important role in planning of staff training activities, work organisation and timely implementation of corrective actions.

Joint effects of risk factors on adverse events associated with adult blood donations

The process for blood donation is considered safe, but some adverse events have been reported. Risk factors for adverse events were assessed in this study.A retrospective case-control study was conducted to investigate the risk factors for adverse events after blood donation between 2010 and 2013. Variables such as gender, age, body mass index (BMI), donation status, donation volume, donation site, pre-donation systolic blood pressure (SBP), and pre-donation diastolic blood pressure were compared between donors with and without adverse events. Multiple logistic regression analysis was performed to assess the joint effects of age, gender, and donation status on adverse events.The incidence of adverse events among adult blood donations was 1287/1,253,678 (0.1%). On multivariate logistic regression analysis, blood donors aged <35 years (odds ratio [OR], 2.99, 95% confidence interval [CI], 2.57-3.48), of female gender (OR, 3.30, 95% CI, 2.62-4.15), and with first-time donor status (OR, 6.40, 95% CI, 5.17-7.93), donation of 500 mL (OR, 2.22, 95% CI, 1.83-2.69), predonation SBP <124 mm Hg (OR, 1.25, 95% CI,1.05-1.48) and BMI <24 kg/m (OR, 1.67, 95% CI, 1.42-1.96) were associated with increased likelihood of adverse event. Further analysis with joint effects method revealed that first-time female donors aged <35 years are associated with the highest odds of adverse events when compared with repeat male donors aged ≧35 years (OR, 100.57, 95% CI, 48.45-208.75).The findings of our study should prove useful in identifying donors at risk and planning appropriate strategies for the prevention of adverse effects.

Beyond Description: The Predictive Role of Affect, Memory, and Context in the Decision to Donate or Not Donate Blood

Background

Research on the recruitment and retention of blood donors has typically drawn on a homogeneous set of descriptive theories, viewing the decision to become and remain a donor as the outcome of affectively cold, planned, and rational decision-making by the individual. While this approach provides insight into how our donors think about blood donation, it is limited and has not translated into a suite of effective interventions. In this review, we set out to explore how a broader consideration of the influences on donor decision-making, in terms of affect, memory, and the context in which donation takes place, may yield benefit in the way we approach donor recruitment and retention.

Summary

Drawing on emerging research, we argue for the importance of considering the implications of both the positive and the negative emotions that donors experience and we argue for the importance of directly targeting affect in interventions to recruit nondonors. Next, we focus on the reconstructed nature of memory and the factors that influence what we remember about an event. We discuss how these processes may impact the retention of donors and the potential to intervene to enhance donors' recollections of their experiences. Finally, we discuss how our focus on the individual has led us to neglect the influence of the context in which donation takes place on donor behavior. We argue that the amassing of comprehensive large data sets detailing both the characteristics of the individuals and the context of their giving will ultimately allow for the more effective deployment of resources to improve recruitment and retention.

Key Messages

In suggesting these directions for future research, our want is to move beyond the ways in which we have traditionally described blood donation behavior with the aim of improving our theorizing about donors while improving the translational value of our research.

International haemovigilance: what have we learned and what do we need to do next?

The International Haemovigilance Network (IHN) defines haemovigilance as 'a set of surveillance procedures covering the whole transfusion chain (from the collection of blood and its components to the follow-up of recipients), intended to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products, and to prevent their occurrence or recurrence'. IHN, the International Society of Blood Transfusion and World Health Organization work together to support both developing and established haemovigilance systems. Haemovigilance systems provide valuable data on a range of adverse events related to blood donation and clinical transfusion, from donor syncopal events to transfusion-transmitted infections, immunological complications and the impact of human errors. Harmonised definitions for most adverse reactions have been developed and validated internationally. Definitions of pulmonary complications are again under review. Haemovigilance data have resulted in changes in policy, products and practice, and can complement and inform clinical audit and research, leading to improved blood donor safety, optimised product use and better clinical outcomes after transfusion. However, more work is needed. Not all countries have haemovigilance systems in place. More robust data and careful analysis are required to improve the understanding of the causes, occurrence and clinical outcomes of these events. Wider dissemination of results will facilitate health policy development internationally, and implementation of haemovigilance recommendations will support further important progress in blood safety.

Feasibility of a pilot intervention to reduce pain and syncope during adolescent vaccination

PURPOSE

Vaccines recommended for adolescents are considered safe and effective, however administration may occasionally result in acute pain at the injection site or syncope (fainting). These adverse effects pose a risk to patient safety and are potential barriers to adherence to future vaccinations. We assessed a novel intervention designed to help prevent acute pain and syncope associated with adolescent vaccinations.

METHODS

We conducted a 3-month pilot study to assess the feasibility and acceptability of a vaccination comfort menu within two Kaiser Permanente Northwest pediatric clinics. The menu offered a variety of comfort items (e.g., cold packs, squeeze balls) that children could select prior to their vaccination. We surveyed parents of recently vaccinated adolescents and interviewed providers to assess the implementation and effectiveness of the intervention.

RESULTS

Response rate for the parent survey was 33% (378/1136). Only 20% of the parents reported that their provider offered the comfort menu during the vaccination visit. Approximately 50% of the adolescents who were offered the menu selected a comfort item and most of these participants reported that the item was very (35%) or somewhat (38%) helpful in improving their vaccination experience. Per provider interviews, common barriers to implementing the intervention included lack of time and convenience, and the brevity of the pilot period.

CONCLUSIONS

The comfort menu may improve the vaccination experience of youth and increase the likelihood of adherence with future vaccinations. However, only 20% of the parents reported that their provider offered the menu during the vaccination visit. Additional research is needed to determine the feasibility of implementing this intervention on a larger scale, as well as assessing whether the intervention has a significant impact on reducing adverse events.

Population Screening for Hereditary Haemochromatosis in Australia: Construction and Validation of a State-Transition Cost-Effectiveness Model

INTRODUCTION

HFE-associated haemochromatosis, the most common monogenic disorder amongst populations of northern European ancestry, is characterised by iron overload. Excess iron is stored in parenchymal tissues, leading to morbidity and mortality. Population screening programmes are likely to improve early diagnosis, thereby decreasing associated disease. Our aim was to develop and validate a health economics model of screening using utilities and costs from a haemochromatosis cohort.

METHODS

A state-transition model was developed with Markov states based on disease severity. Australian males (aged 30 years) and females (aged 45 years) of northern European ancestry were the target populations. The screening strategy was the status quo approach in Australia; the model was run over a lifetime horizon. Costs were estimated from the government perspective and reported in 2015 Australian dollars ($A); costs and quality-adjusted life-years (QALYs) were discounted at 5% annually. Model validity was assessed using goodness-of-fit analyses. Second-order Monte-Carlo simulation was used to account for uncertainty in multiple parameters.

RESULTS

For validity, the model reproduced mortality, life expectancy (LE) and prevalence rates in line with published data. LE for C282Y homozygote males and females were 49.9 and 40.2 years, respectively, slightly lower than population rates. Mean (95% confidence interval) QALYS were 15.7 (7.7-23.7) for males and 14.4 (6.7-22.1) for females. Mean discounted lifetime costs for C282Y homozygotes were $A22,737 (3670-85,793) for males and $A13,840 (1335-67,377) for females. Sensitivity analyses revealed discount rates and prevalence had the greatest impacts on outcomes.

CONCLUSION

We have developed a transparent, validated health economics model of C282Y homozygote haemochromatosis. The model will be useful to decision makers to identify cost-effective screening strategies.