Transfusion-associated adverse events and implementation of blood safety measures - findings from the 2017 National Blood Collection and Utilization Survey

Evidence of content validity of the "Blood Transfusion Reaction" (code 0700) nursing outcome from the nursing outcomes classification

OBJECTIVE

The objective of study was to present evidence of the content validity of conceptual and operational definitions of the "Blood Transfusion Reaction (code 0700)" nursing outcome from the Nursing Outcomes Classification (NOC).

METHOD

A methodological study was implemented in four phases. The first phase consisted of a narrative literature review in which the main indicators related to blood transfusion were identified: 25 new indicators that were not present in NOC, in addition to 14 existing indicators, for a total of 39 to be studied. In the second phase, conceptual and operational definitions, and magnitude of NOC indicators were developed. The third phase consisted of analysis of evidence of content validity of conceptual and operational definitions of indicators, through assessment by experts. In the fourth phase, a pilot test was applied to 40 electronic medical records of patients who received blood components and presented with a transfusion reaction.

RESULTS

A total of 27 articles were analyzed and served as support to develop conceptual and operational definitions, and magnitude of indicators, considered for the outcome under study. It was assessed by a group of 10 experts, requiring three rounds to reach the established critical content validity ratio in which four of these indicators were excluded, leaving 35 indicators in the final version. A pilot test on 40 records revealed the presence of 13 indicators, of which six were present in the classification.

CONCLUSION

The conceptual and operational definitions and magnitude developed for the "Blood Transfusion Reaction (code 0700)" nursing outcome demonstrated adequate evidence of content validity in the 21 indicators found in the literature, along with 14 indicators already present in NOC, and 13 of these indicators were present in patients receiving blood components who presented a transfusion reaction.

IMPLICATIONS FOR PRACTICE

Nurses can use this nursing outcome as a clinical assessment tool for monitoring blood transfusion recipients' clinical signs.

Supplemental findings of the 2021 National Blood Collection and Utilization Survey

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 use. Supplemental data from the 2021 NBCUS not presented elsewhere are presented here.

METHODS

Data on survey participation, donor characteristics, blood component cost, transfusion-associated adverse reactions, and implementation of blood safety measures, including pathogen-reduction of platelets, during 2021, were analyzed. Comparisons are made to 2019 survey data where available (2013-2019 for survey participation).

RESULTS

During 2021, there were 11,507,000 successful blood donations in the United States, a 4.8% increase from 2019. Persons aged 45-64 years accounted for 42% of all successful blood donations. Donations by persons aged 65 years and older increased by 40.7%, while donations among minorities and donors aged <25 years decreased. From 2019 to 2021, the median price hospitals paid per unit of leukoreduced red blood cells, leukoreduced and pathogen-reduced apheresis platelets, and fresh frozen plasma increased. The largest increase in price per unit of blood component in 2021 was for leukoreduced apheresis platelets, which increased by ~$51. Between 2019 and 2021, the proportion of transfusing facilities reporting use of pathogen-reduced platelets increased, from 13% to 60%. Transfusion-related adverse reactions declined slightly between 2019 and 2021, although the rate of transfusion-transmitted bacterial infections remained unchanged.

CONCLUSION

During 2021, blood donations increased nationally, although donations from those aged <25 years and minorities declined. The prices hospitals paid for most blood products increased, as did the use of pathogen-reduced platelets.

Transfusion-Transmitted Disorders 2023 with Special Attention to Bone Marrow Transplant Patients

Transfusion medicine is traditionally a strong/fundamental part of clinical practice, saving hundreds of millions of lives. However, blood-borne or transmitted infections are a well-known and feared possibility, a risk we relentlessly mitigate. Pathogens are continuously and rather quickly changing, so during the last decade, many, sometimes exotic, new pathogens and diseases were recorded and analyzed, and some of them were proved to be transmitted with transfusions. Blood or blood component transfusions are carried out after cautious preparative screening and inactivation maneuvers, but in some instances, newly recognized agents might escape from standard screening and inactivation procedures. Here, we try to focus on some of these proven or potentially pathogenic transfusion-transmitted agents, especially in immunocompromised patients or bone marrow transplantation settings. These pathogens are sometimes new challenges for preparative procedures, and there is a need for more recent, occasionally advanced, screening and inactivation methods to recognize and eliminate the threat a new or well-known pathogen can pose. Pathogen transmission is probably even more critical in hemophiliacs or bone marrow transplant recipients, who receive plasma-derived factor preparations or blood component transfusions regularly and in large quantities, sometimes in severely immunosuppressed conditions. Moreover, it may not be emphasized enough that transfusions and plasma-derived product administrations are essential to medical care. Therefore, blood-borne transmission needs continued alertness and efforts to attain optimal benefits with minimized hazards.

Systematic Review with Meta-Analysis: Efficacy and Safety of Lusutrombopag for Severe Thrombocytopenia in Patients with Chronic Liver Disease Undergoing Invasive Procedures

INTRODUCTION

Lusutrombopag is an oral thrombopoietin receptor agonist (TPO-RA). Clinical trials have shown lusutrombopag's efficacy in reducing need for preoperative platelet transfusion in patients with chronic liver disease (CLD) and severe thrombocytopenia. This analysis assessed efficacy and safety of lusutrombopag in patients with severe thrombocytopenia and CLD undergoing planned invasive procedures.

METHODS

An electronic database search (through 1 December 2020) identified three randomised, placebo-controlled, double-blind clinical trials comparing lusutrombopag with placebo in patients with CLD and platelet count below 50 × 109/L scheduled to undergo a procedure with a perioperative bleeding risk. A random-effects meta-analysis examined treatment effect, with Cochrane Collaboration's tool assessing risk of bias.

RESULTS

The meta-analysis included 343 (lusutrombopag 3 mg, n = 173; placebo, n = 170) patients. More patients met the criteria for treatment response (platelet count at least 50 × 109/L and increase of at least 20 × 109/L from baseline anytime during the study) with lusutrombopag versus placebo (risk ratio [RR] 6.39; 95% confidence interval [CI] 3.69, 11.07; p < 0.0001). The primary efficacy outcome, proportion of patients requiring no platelet transfusion and no rescue therapy for bleeding for at least 7 days post procedure, was achieved by more patients treated with lusutrombopag versus placebo (RR 3.42; 95% CI 1.86, 6.26; p = 0.0001). The risk of any bleeding event was significantly lower with lusutrombopag compared to placebo (RR 0.55; 95% CI 0.32, 0.95; p = 0.03); conversely, thrombosis event rates were similar between lusutrombopag and placebo (RR 0.79; 95% CI 0.19, 3.24; p = 0.74).

CONCLUSION

This meta-analysis showed that treatment of severe thrombocytopenia with lusutrombopag in patients with CLD prior to a planned invasive procedure was efficacious and safe in increasing platelet counts, avoiding the need for platelet transfusions, and reducing risk of bleeding, thereby enhancing the certainty of evidence supporting the efficacy and safety of lusutrombopag.

Expanded validation of the effect and quality of a pathogen inactivation system based on riboflavin photochemistry on platelet bacterial contamination

Background

Bacterial contamination still poses serious challenges to blood safety. Platelets have the highest bacterial contamination risk of all blood components.

Methods

Twenty units of manual platelets were prepared from blood donated by our hospital, which were inoculated with Staphylococcus aureus and Escherichia coli suspensions. The riboflavin sodium phosphate solution was added into platelets, adjusted to a final concentration of 160 μmol/L. Platelets added into an illumination bag and placed in the inactivation system for riboflavin photochemistry at various doses. The inactivation effect of bacteria was evaluated on a Columbia blood agar plate by the plate counting method. Meanwhile, the blood routine, blood gas analysis, platelet aggregation test, and thromboelastogram of platelets before and after treatment were detected to evaluate the changes of platelet quality after treatment.

Results

the inactivation effect of S. aureus and E. coli at the inactivation dose (16.9 J/cm²) could reach more than 4 logs. After treatment at 16.9 J/cm², the blood routine results showed that the platelet count was significantly different (P<0.05), and the blood gas analysis showed that the oxygen partial pressure (pO₂) and lactic acid concentration (cLac) were also significantly different (P<0.05). After 16.9 J/cm² treatment, there was a significant difference between Arachidonic acid (AA) and Collagen (Cog) activator groups in the platelet aggregation experiment (P<0.05), but there was no significant difference in the main thrombelastogram (TEG) parameters (R value, K value, angle value, MA value) after treatment (P>0.05).

Conclusions

The inactivation effect of this set of blood component pathogen inactivation system on platelet bacterial contamination could be considered to meet actual clinical needs, with the inactivation treatment having little impact on platelet function.

A Single-Center Description of Pediatric Transfusion Reactions and Preventable Patient Harm

BACKGROUND AND OBJECTIVES

In previous studies, researchers highlight that children have higher rates of transfusion reactions than adults. However, little is known about the pediatric populations that experience reactions, and there are no reports that consider appropriateness of pediatric transfusions in relation to preventable harm. With this study, we aim to describe pediatric transfusion reactions occurring at an academic institution and to quantify transfusion reactions that resulted from inappropriate transfusion indications, thereby identifying an area of potentially preventable patient harm (PPH).

METHODS

This is a case series of acute transfusion reactions in pediatric patients at a single institution from January 2018 to December 2019. We reviewed patient data, clinical documentation, and transfusion reaction reports to determine the appropriateness of transfusions and calculate PPH.

RESULTS

A total 155 acute transfusion reactions occurred in 106 pediatric patients, amounting to a total reaction rate of 544 of 100 000 transfusions. In 65% of reactions, the indication for transfusion was appropriate by institutional standards; 23% had questionable indication; and 12% were not indicated. The rate of potential PPH from inappropriate transfusions was 67 of 100 000 transfusions.

CONCLUSIONS

Transfusion reactions that occur during inappropriately ordered blood transfusions represent PPH. Efforts should be made to develop transfusion guidelines, standardize practice, and educate physicians to prevent transfusion-related harm.

Pathogen-reduced platelets in pediatric and neonatal patients: Demographics, transfusion rates, and transfusion reactions

BACKGROUND

Pathogen-reduced platelets (PR PLT) are the emerging standard for proactive transfusion-transmitted infection (TTI) mitigation. There is, however, continued hesitation to transfuse PR PLT in children due to limited published data. We report demographics, rates of transfusion, and transfusion reactions (TR) associated with FDA-approved PR PLT in pediatric and neonatal patients at an academic medical center.

METHODS

Retrospective review was performed for patients <18 years receiving at least one platelet over a 300-day period at a large, tertiary care hospital. Patients were transfused PR or conventional (CONV) PLT, based on inventory availability. Statistical analysis was performed using Fisher Exact Test.

RESULTS

During the study period, 191 patients received 1010 platelet transfusions (892 units). Sixty-eight patients received PR PLT only (1.3 units/patient, 95% confidence interval [CI] 1.1-1.5; 1.8 transfusions/patient, 95% CI 1.4-2.2), and 56 patients received CONV PLT only (1.4 units/patient, 95% CI 1.1-1.7; 1.6 transfusions/patient, 95% CI 1.3-1.9). Patients with hematologic malignancies undergoing chemotherapy/radiation and allogeneic hematopoietic stem cell transplant received the most platelet transfusions and more commonly received both platelet types. Of 506 PR PLT units, 5 TRs occurred; 386 CONV PLT resulted in two TRs (p = .7052). Of 51 neonates, 37 received PR PLT without adverse events, including 13 receiving phototherapy. No TTIs were identified in any group.

CONCLUSION

There was no significant difference in rates of transfusion or TRs between PR and CONV PLT. Our study provides additional evidence that PR PLT can be transfused to pediatric and neonatal patients without increasing the risk of acute adverse events.

Transfusion-related adverse reactions: Data from the National Healthcare Safety Network Hemovigilance Module - United States, 2013-2018

BACKGROUND

Despite current blood safety measures, transfusion recipients can experience transfusion-related adverse reactions. Monitoring these reactions can aid in understanding the effectiveness of current transfusion safety measures. Data from the National Healthcare Safety Network Hemovigilance Module were used to quantify adverse reaction risk.

METHODS

Facilities reporting at least one month of transfused blood components and transfusion-related adverse reactions during January 2013-December 2018 were included. Adverse reaction rates (number per 100,000 components transfused) were calculated for transfused components stratified by component type, collection, and modification methods.

RESULTS

During 2013-2018, 201 facilities reported 18,308 transfusion-related adverse reactions among 8.34 million blood components transfused (220/100,000). Adverse reactions were higher among apheresis (486/100,000) and pathogen-reduced platelets (579/100,000) than apheresis red blood cells (197/100,000). Allergic reactions (41%) were most common. There were 23 fatalities and 9% of all adverse reactions were serious (severe, life-threatening, or fatal). Reactions involving pulmonary complications (transfusion-associated circulatory overload, transfusion-related acute lung injury and transfusion-associated dyspnea) accounted for 35% of serious reactions but 65% of fatalities. Most (76%) of the 37 transfusion-transmitted infections were serious; none involved pathogen-reduced components.

CONCLUSIONS

One in 455 blood components transfused was associated with an adverse reaction although the risk of serious reactions (1 in 6224) or transfusion-transmitted infections (1 in 225,440) was lower. Some serious reactions identified were preventable, suggesting additional safety measures may be beneficial. Higher reaction rates identified among pathogen-reduced platelets require further study. These findings highlight the importance of monitoring reactions through national hemovigilance to inform current safety measures and the need for strategies to increase healthcare facility participation.

Hypothermic storage of leukoreduced red blood cells for greater than 21 days is a safe alternative to irradiation

BACKGROUND

Irradiation of red blood cells (RBCs) inactivates residual donor T lymphocytes to prevent transfusion-associated graft-vs-host disease (TA-GVHD) but can have adverse effects on recipients and inventory management. Reported incidence of TA-GVHD is lower when leukoreduced RBCs and older blood products are transfused; therefore, the impact of leukoreduction and storage was evaluated as an alternative prevention strategy.

STUDY DESIGN AND METHODS

Effectiveness of leukoreduction filters on white blood cell (WBC) proliferation was evaluated by filtering buffy coat (BC) products and isolating residual WBCs. Additionally, leukoreduced RBCs were spiked with 5 × 10⁶ WBCs on Day 21 of hypothermic storage, then stored and processed on Days 7, 14, and 21 to obtain residual WBCs to investigate the impact of hypothermic storage on their viability and proliferative ability. Viability of residual WBCs was assessed by staining with annexin V and an antibody cocktail for flow cytometry analysis. Proliferative ability was assessed by placing carboxyfluorescein diacetate succinimidyl ester-labeled residual WBCs into culture for 6 days with phytohemagglutinin before flow cytometry assessment.

RESULTS

Filtration of BC units depleted WBCs, particularly T lymphocytes, to 0.001% ± 0.003% cells/unit, although proliferative activity remained consistent with prefiltration levels of WBCs. WBCs in stored RBCs remained viable even on Day 21 of storage; however, the proliferative activity decreased to 0.24% ± 0.41%.

CONCLUSIONS

Hypothermic storage of RBCs for 21 days or more is sufficient to inactivate T lymphocytes, which may help prevent TA-GVHD when irradiated RBCs are not available.

Transfusion-Associated Hyperkalemic Cardiac Arrest in Neonatal, Infant, and Pediatric Patients

Red blood cell (RBC) transfusions are a life-saving intervention, with nearly 14 million RBC units transfused in the United States each year. However, the safety and efficacy of this procedure can be influenced by variations in the collection, processing, and administration of RBCs. Procedures or manipulations that increase potassium (K⁺) levels in stored blood products can also predispose patients to hyperkalemia and transfusion-associated hyperkalemic cardiac arrest (TAHCA). In this mini review, we aimed to provide a brief overview of blood storage, the red cell storage lesion, and variables that increase extracellular [K⁺]. We also summarize cases of TAHCA and identify potential mitigation strategies. Hyperkalemia and cardiac arrhythmias can occur in pediatric patients when RBCs are transfused quickly, delivered directly to the heart without time for electrolyte equilibration, or accumulate extracellular K⁺ due to storage time or irradiation. Advances in blood banking have improved the availability and quality of RBCs, yet, some patient populations are sensitive to transfusion-associated hyperkalemia. Future research studies should further investigate potential mitigation strategies to reduce the risk of TAHCA, which may include using fresh RBCs, reducing storage time after irradiation, transfusing at slower rates, implementing manipulations that wash or remove excess extracellular K⁺, and implementing restrictive transfusion strategies.

Transfusion Reactions in Pediatric Patients: An Analysis of 5 Years of Hemovigilance Data From a National Center for Children's Health in China

Objective: This study aimed to describe transfusion reactions of pediatric patients from a National Center for Children's Health in China and to examine reaction incidents, reaction types by blood transfusion, and the associated blood products resulting in transfusion reactions. Methods: We compared transfusion reaction rates, among platelets, plasma, and red blood cells (RBCs) using a retrospective analysis of pediatric patients treated with blood transfusion based on data from the National Center for Children's Health (Beijing, China) by a hemovigilance reporting system from January 2015 to December 2019. Results: Over the past 5 years, 165 reactions were reported, and the overall incidence was 1.35‰ (95% CI: 1.14-1.55‰; 165/122,652); for each separate year, the incidences were 1.25‰ (95% CI: 0.76-1.74‰; 25/20,035; 2015), 1.09‰ (95% CI: 0.65-1.52‰; 24/22,084; 2016), 1.66‰ (95% CI: 1.14-2.18‰; 39/23,483; 2017), 1.36‰ (95% CI: 0.92-1.81‰; 36/26,440; 2018) and 1.34‰ (95% CI: 0.93-1.75‰; 41/30,610; 2019). Transfusion reaction incidents by person included 0.37‰ (95% CI: 0.21-0.53‰; 21/56,815) RBCs, 2.98‰ (95% CI: 2.33-3.64‰; 79/26,496) platelets and 1.65‰ (95% CI: 1.25-2.05‰; 65/39,341) frozen plasma. According to the analysis by blood products, the incidence of transfusion was 0.34‰ (95% CI: 0.20-0.48‰; 23/66,958) for RBCs, 3.21‰ (95% CI: 2.50-3.92‰; 78/24,318.5) for platelets, and 0.94‰ (95% CI: 0.71-1.17‰; 64/67,912) for frozen plasma. Transfusion reactions were most commonly associated with platelets, followed by plasma and RBC transfusions. The types of blood transfusion reactions were mainly allergic reactions (86.67%) and febrile non-hemolytic transfusion reactions (FNHTRs, 4.24%). The disease types of pediatric patients with transfusion reactions were concentrated among those with blood system diseases. A total of 80.61% of children with transfusion reactions had a previous blood transfusion history. Conclusions: Transfusion reactions are still relatively common in pediatric patients, and additional studies are necessary to address the differences in reaction rates, especially allergic and FNHTRs. Robust hemovigilance systems do include a special section dedicated to children will further the understanding of these reactions and trends, and prospective randomized clinical controlled trials may need to be conducted to perform preventive and corrective measures.

Potential Consequences of the Red Blood Cell Storage Lesion on Cardiac Electrophysiology

Background The red blood cell (RBC) storage lesion is a series of morphological, functional, and metabolic changes that RBCs undergo following collection, processing, and refrigerated storage for clinical use. Since the biochemical attributes of the RBC unit shifts with time, transfusion of older blood products may contribute to cardiac complications, including hyperkalemia and cardiac arrest. We measured the direct effect of storage age on cardiac electrophysiology and compared it with hyperkalemia, a prominent biomarker of storage lesion severity. Methods and Results Donor RBCs were processed using standard blood-banking techniques. The supernatant was collected from RBC units, 7 to 50 days after donor collection, for evaluation using Langendorff-heart preparations (rat) or human induced pluripotent stem cell-derived cardiomyocytes. Cardiac parameters remained stable following exposure to "fresh" supernatant from red blood cell units (day 7: 5.8±0.2 mM K+), but older blood products (day 40: 9.3±0.3 mM K+) caused bradycardia (baseline: 279±5 versus day 40: 216±18 beats per minute), delayed sinus node recovery (baseline: 243±8 versus day 40: 354±23 ms), and increased the effective refractory period of the atrioventricular node (baseline: 77±2 versus day 40: 93±7 ms) and ventricle (baseline: 50±3 versus day 40: 98±10 ms) in perfused hearts. Beating rate was also slowed in human induced pluripotent stem cell-derived cardiomyocytes after exposure to older supernatant from red blood cell units (-75±9%, day 40 versus control). Similar effects on automaticity and electrical conduction were observed with hyperkalemia (10-12 mM K+). Conclusions This is the first study to demonstrate that "older" blood products directly impact cardiac electrophysiology, using experimental models. These effects are likely caused by biochemical alterations in the supernatant from red blood cell units that occur over time, including, but not limited to hyperkalemia. Patients receiving large volume and/or rapid transfusions may be sensitive to these effects.

Supplemental findings of the 2017 National Blood Collection and Utilization Survey

INTRODUCTION

This report provides supplemental results from the 2017 National Blood Collection and Utilization Survey on characteristics of the donor population, autologous and directed donations and transfusions, platelets, plasma and granulocyte transfusions, pediatric transfusions, severe donor-related adverse events, cost of blood units, hospitals policies and practices, and inventory, dosing, and supply.

METHODS

Weighting and imputation were used to generate national estimates including number of donors, donations, donor deferrals, autologous and directed donations and transfusions, severe donor-related adverse events, platelet and plasma collections and transfusions, number of cross-match procedures, irradiation and leukoreduction, and pediatric transfusions.

RESULTS

Between 2015 and 2017, successful donations decreased slightly by 2.1% with a 10.3% decrease in donations by persons aged 16-18 years and a 14.4% increase in donations by donors aged >65 years. The median price paid for blood components by hospitals decreased from $211 to $207 for leukoreduced red blood cell units, from $523 to $517 for leukoreduced apheresis platelet units, and from $54 to $51 for fresh frozen plasma units. Plasma transfusions decreased 13.6%, but group AB plasma units transfused increased 24.7%.

CONCLUSION

Between 2015 and 2017, blood donations declined slightly because of decreases in donations from younger donors, but the number of donations from older donors increased. The price hospitals pay for blood has continued to decrease. Plasma transfusions have decreased, but the proportion of plasma transfusions involving group AB plasma have increased.