Early Transfusion of Convalescent Plasma Improves the Clinical Outcome in Severe SARS-CoV2 Infection

INTRODUCTION

Plasma harvested from convalescent COVID-19 patients (CCP) has been applied as first-line therapy in the early phase of the SARS-CoV2 pandemic through clinical studies using various protocols.

METHODS

We present data from a cohort of 267 hospitalized severe COVID-19 patients who received CCP. No transfusion-related complications were reported, indicating the overall safety of CCP therapy.

RESULTS

Patients who eventually died from COVID-19 received CCP significantly later (3.95 versus 5.22 days after hospital admission) and had higher interleukin 6 (IL-6) levels (28.9 pg/ml versus 102.5 pg/ml) than those who survived. In addition, CCP transfusion caused a significant reduction in the overall inflammatory status of the patients regardless of the severity of disease or outcome, as evidenced by decreasing C-reactive protein, IL6 and ferritin levels.

CONCLUSION

We conclude that CCP transfusion is a safe and effective supplementary treatment modality for hospitalized COVID-19 patients characterized by better expected outcome if applied as early as possible. We also observed that IL-6 may be a suitable laboratory parameter for patient selection and monitoring of CCP therapy effectiveness.

National level adjustments to the challenges of the SARS-CoV2 pandemic on blood banking operations

Background

SARS‐CoV2 causing coronavirus disease (COVID‐19) is responsible for an unprecedented worldwide pandemic severely affecting all activities of societies including blood banking. We aimed to systematically collect key indicators in a nationally centralized blood banking system and to perform comparisons between 2020 and 2019.

Methods

Count data for January–December 2020 and 2019 were extracted from the integrated informatics system of Hungarian National Blood Transfusion Service and analyzed by simple graphics, tabulations, and statistics.

Results

Whole blood donation activity showed a highly significant decline due to a sharp decrease in field donations by an average fall of 24% (range:17%–28%) during March–May 2020 compared to identical period of 2019. A second, more moderate decline accompanied the second wave in late fall. The simultaneous increase in institutional donations did not counterbalance this decline. Donor exclusion rates fell significantly by an average of 1,1% (range:0.9%–1.6%) in the three spring lockdown‐affected months. First‐time and repeat donors showed decreased turn‐out in larger proportions compared to highly repeat donors. Interestingly, among repeat and highly repeat donors, females showed less‐pronounced declines compared to males while this was not observed among first‐time donors. In June–September, a remarkable swing‐back was observed among highly repeat female donors. Product utilization fell most notably for RBC (mean:26.2%) but also for PLT (mean:19.8%) and FFP (mean:24.3%) and showed a full recovery in June–September followed by a second decline.

Conclusion

Trends and reaction patterns of blood banking reported by our study may be useful in future planning and adjustments of blood banking activities.

Principles of the perioperative Patient Blood Management

The perioperative Patient Blood Management (in Hungary National Blood Donation and Blood Saving Program) is an individualized clinical practice based on a multidisciplinary consensus with a comprehensive and complex approach. It supports the rational and judicious utilization of blood products and abolishes irrational transfusion policy. Its practical implementation is based upon three pillars: 1. anemia management without transfusion, if possible; restrictive transfusion strategy; 2. minimization of blood loss; 3. enhancement of anemia tolerance. Early detection, clarification of etiology and appropriate treatment are the most important tools for the management of preoperative anemia before surgeries with a high risk of bleeding. Minimization of blood loss can be achieved by identifying patients with congenital or acquired bleeding disorders, preparing them appropriately for surgery, discontinuing anticoagulants and antiplatelet drugs for a sufficient time in the preoperative phase of surgery and reversing their effects to comply with current guidelines. Minimal-invasive approaches are preferable. Intraoperatively, atraumatic technique and accurate topical haemostasis should be provided by surgeons. Autologous blood salvage techniques and controlled hypotension in lack of contraindications can also reduce the amount of blood loss. In cases of perioperative bleeding, protocols based on international guidelines but adapted to local circumstances must be used. Ideally, it should be managed by viscoelastic test-guided, goal-directed, individualized and factor concentrate-based algorithm. Perioperatively, an ideal oxygen demand/supply ratio must be ensured to avoid oxygen debt. Restoration and maintenance of homeostasis are essential for both the effectively functioning haemostatic system and the avoidance of oxygen deficit. Implementation of the Patient Blood Management improves patient safety, reduces the cost of medical care and facilitates the national blood product supply. Its successful introduction is our common interest. Orv Hetil. 2020; 161(37): 1554-1568.

Perioperative Patient Blood Management: common risk, common tasks, common responsibility

Human red blood cell concentrate and platelet suspension are unstable preparations, therefore, they are not part of the international pharmaceutical market for biological and economic reasons. Consequently, they cannot be replaced by external sources. Human allogeneic erythrocyte and platelet preparations should therefore be considered as part of the common national wealth. The amount of transfused red blood cell concentrate has been declining in countries with advanced health systems in recent years. The changes were initially driven by the spread of the concept and practice of liberal and restrictive transfusion triggers. A complex, thoughtful system of perioperative blood utilization, the Patient Blood Management has later emerged, and a paradigm shift in the delivery of life-threatening perioperative bleeding has developed. At the same time, clinical practitioners are facing a new challenge of reducing willingness to donate blood worldwide. The rationalization of the use of human red blood cell concentrate and platelet suspension is essential in Hungary. As a health care measure, the currently rigidly earmarked financial resources available for allogeneic preparations and stable factor concentrates for the treatment of life-threatening haemorrhages need to be changed to be interoperable. The perioperative blood use could additionally be reduced by the widespread dissemination of the Patient Blood Management requiring complex coordinated educational interdisciplinary and logistical work. Orv Hetil. 2020; 161(37): 1545-1553.

National Blood Donation and Blood Saving Program in Hungary. Further steps are required to improve patient safety

INTRODUCTION AND AIM

In the last decade, guidelines and trainings promoted haemostasis point-of-care tests, availability and application of factor products, while they led to a decrease in blood product consumption. The aim of this study is to examine protocols, conditions in terms of facilities, equipment, personnel of anaesthesia-intensive care units (A-ICU) to improve healthcare services and patient safety.

METHOD

In 2019, self-reported questionnaires were sent in e-mail to A-ICUs. Application of guidelines and local protocols, education, haemostasis diagnostic tools, availability of allogeneic transfusion products, stable factor and drug products for restoring haemostasis were evaluated.

RESULTS

49% of A-ICUs filled out 46 questionnaires. 91.3% applied guidelines, 43.5% had local protocols. The lack of haemostasis and Patient Blood Management (PBM) trainings was indicated by 6 and 17 A-ICUs, respectively. Applying MAITT guidelines decreased red blood cell concentrate (RBC), fresh frozen plasma (FFP) and thrombocyte consumption by 65.1%, 67.4% and 30.2%. The availability of laboratory and viscoelastic tests is limited except for blood count, INR, APTI, fibrinogen. Where viscoelastic tests were available, RBC 2.9, FFP 1.7, thrombocyte 2.5 times more physicians per A-ICU beds participated in haemostasis trainings. 32% of A-ICUs can provide the required amount of factor products in the case of massive bleeding.

CONCLUSION

Haemostasis and PBM trainings improve the quality of healthcare services if necessary equipment, factor and haemostasis drug products are provided. In order to promote PBM programmes and to improve patient safety, rearrangement of service and financing structure is needed, which must be accompanied by consulting perioperative professionals, general practitioners, and other related experts. Orv Hetil. 2020; 161(37): 1606-1616.

[Forced steps for making improvements in severe perioperative haemorrhage]

Severe perioperative bleeding increases perioperative morbidity and mortality. The management of the consequences imposes high burden on the human and financial resources of healthcare providers. Since 2009, there has been a continued worldwide decline in demand for allogenic blood products. This tendency can mainly be attributed to Perioperative Blood Management Program and to new innovative management applying haemostatic factor concentrates, viscoelastic assays and guidelines for treatment of the severe periprocedural bleeding patients. One of the major challenges of our times is still to match blood supply with demand. The new diagnostic and therapeutic modalities for managing the bleeding patients require new financial resources on the one hand and, on the other hand, call for redistribution of the material means provided by the health care system. Achieving interoperability between financial resources allocated to allogenic blood products and factor concentrates, the current state-of-the-art approach for managing the bleeding patient can be used to save blood and the lives of patients simultaneously. Orv Hetil. 2019; 160(6): 203-213.

[Personnel and material conditions of the Hungarian intensive care units dealing with organ donation]

INTRODUCTION

At the end of 2016, the number of patients on the domestic transplant waiting list was twice as much as the number of the organ transplantations accomplished that year. The institutional prerequisites for functional organ donation programs are the sufficient number of personnel and the adequate material conditions to be provided in relation to the needs.

AIM

The goal of the current study was to evaluate the professional environment in Hungary.

METHOD

The Organ Coordination Office at the Hungarian National Blood Transfusion Service compiled a questionnaire survey on the personnel and material conditions of the intensive care units (ICUs) in Hungary in regards to organ donations. The survey applied an online questionnaire including 43 questions. In addition to the number of beds and employees, we investigated the tools needed for the legal and the medical diagnosis of brain death as well as the accessibility of examinations on the donor information form. The data collection spanned from 12 December 2016 to 30 June 2017.

RESULTS

59 intensive care units completed the questionnaire; the investigation involved 640 hospital beds, 816 physicians and 1252 nurses. In the daytime shift, 0.25 doctors and 0.41 nurses work on a patient bed at an average, while in the night shift, the figures are 0.11 and 0.33, respectively. 51.7% of the doctors are registered to access the National Non-Donor Registry, and brain death diagnosis committee is available in 83% of the hospitals. Among the medical imaging methods (cranial, abdominal-thoracic), CT scan in 71-73%, abdominal ultrasound in 75%, transthoracic echocardiograpy (TTE) in 37%, transoesophageal echocardiography (TEE) in 4%, bronchoscopy in 49%, coronarography in 19% are non-stop available, with instant interpretation in 75% of the cases. Transcranial Doppler (TCD) in 30%, four-vessel angiography in 45% and SPECT in 14% of the cases are available. More than 90% of the laboratory examinations on the donor information form are available 24 hours a day.

CONCLUSION

The number of doctors and nurses did not change compared to our 2008 survey (0.18 doctors, 0.37 nurses/ICU beds in 2008), but the care of potential donors needs more resources and time. The standby availability of personnel and material conditions is a prerequisite for organ donation programs in order to save lives. Orv Hetil. 2018; 159(33): 1360-1367.