1
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Nguyen PT, Boral LI, O’Brien J, Zhang D, Gao Y, Bernard A. Reducing Inappropriate Overutilization of the Massive Transfusion Protocol. Am J Clin Pathol 2020. [DOI: 10.1093/ajcp/aqaa161.269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction/Objective
Massive transfusion protocols (MTPs) make it possible to deliver blood products to exsanguinating patients in an efficient, sustained, and immediate manner. However, overutilization of MTPs continues to remain a significant problem for hospital blood banks. The study aims to address the characteristics of possibly inappropriate MTP activations during the first phase (cooler) at a level 1 trauma academic medical center.
Methods
This was a retrospective review of 328 phase 1 MTPs out of 696 total MTPs performed during a two-year period (Jan 1, 2017 and Dec 31, 2018) and divided into three categories: trauma, non-trauma surgery, and medicine services. We assumed that a possibly inappropriate MTP for trauma cases would show an Assessment of Blood Component (ABC) score of 1 or less and physicians used clinical discretion. For possibly inappropriate MTP non- trauma surgical and medicine cases, we devised a new system where we looked at only whether the blood pressure was equal to or less than 90 mm Hg and/or the pulse was greater than or equal to 120 beats per minute. If there was a score of 0 where there were neither vital sign criteria, then the MTP was considered possibly inappropriate.
Results
For trauma service, there were 43/168 (25.6%) cases that had an ABC score of 0, 49/168 (29.2%) cases that had an ABC score of 1, 53/168 (31.5%) cases that had an ABC score of 2, 21/168 (12.5%) cases that had an ABC score of 3, and only 2/168 (1.2%) case that had an ABC score of 4. Non-trauma surgery service had 31/51 (60.8%) cases with a new score of 0, 20/51 (39.2%) cases with a new score of 1, and 0/51 (0%) cases with a new score of 2. Medicine services had 57/109 (52.3%) patients with a new score of 0, 47/109 (43.1%) patients with a new score of 1, and 5/109 (4.6%) patients with a new score of 2. Non-trauma surgery service had the greatest possibly inappropriate MTP activations [31/51 cases (60.8%)], followed by trauma [92/168 (54.8%) cases] and medicine [57/109 (52.3%) cases].
Conclusion
Our study shows greater overutilization with MTPs using clinical judgment than with using the ABC criteria. Non-trauma surgery service had the greatest number of possibly inappropriate MTP activations at our hospital without having a significantly abnormal pulse or blood pressure. While ABC criteria is already liberal for activating an MTP, physician discretion appears to be more liberal in activating a possibly inappropriate MTP.
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Affiliation(s)
- P T Nguyen
- Pathology and Laboratory Medicine, University of Kentucky Healthcare, Lexington, Kentucky, UNITED STATES
| | - L I Boral
- Pathology and Laboratory Medicine, University of Kentucky Healthcare, Lexington, Kentucky, UNITED STATES
| | - J O’Brien
- Pathology and Laboratory Medicine, University of Kentucky Healthcare, Lexington, Kentucky, UNITED STATES
| | - D Zhang
- Pathology and Laboratory Medicine, University of Kentucky Healthcare, Lexington, Kentucky, UNITED STATES
| | - Y Gao
- Pathology and Laboratory Medicine, University of Kentucky Healthcare, Lexington, Kentucky, UNITED STATES
| | - A Bernard
- Pathology and Laboratory Medicine, University of Kentucky Healthcare, Lexington, Kentucky, UNITED STATES
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2
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Onuoha C, Barton KD, Wong EC, Raval JS, Rollins‐Raval MA, Ipe TS, Kiss JE, Boral LI, Adamksi J, Zantek ND, Onwuemene OA. Therapeutic plasma exchange and intravenous immune globulin in the treatment of
heparin‐induced
thrombocytopenia: A systematic review. Transfusion 2020; 60:2714-2736. [DOI: 10.1111/trf.16018] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/29/2020] [Accepted: 07/01/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Chinonso Onuoha
- Department of Pediatrics East Carolina University, Vidant Medical Center Greenville North Carolina USA
| | - Karen D. Barton
- Medical Center Library Duke University Medical Center Durham North Carolina USA
| | - Edward C.C. Wong
- Department of Pediatrics and Pathology George Washington School of Medicine and Health Sciences Washington, DC USA
- Department of Coagulation Quest Diagnostics, Nichols Institute Centreville Virginia USA
| | - Jay S. Raval
- Department of Pathology University of New Mexico Albuquerque New Mexico USA
| | | | - Tina S. Ipe
- Department of Pathology and Laboratory Medicine University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Joseph E. Kiss
- Department of Medicine Vitalant Northeast Division and The University of Pittsburgh Pittsburgh Pennsylvania USA
| | - Leonard I. Boral
- Department of Pathology and Laboratory Medicine University of Kentucky Health Care Lexington Kentucky USA
| | - Jill Adamksi
- Department of Laboratory Medicine and Pathology Mayo Clinic Arizona Phoenix Arizona USA
| | - Nicole D. Zantek
- Department of Laboratory Medicine and Pathology University of Minnesota Minneapolis Minnesota USA
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3
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Abstract
OBJECTIVES We discuss two main categories of blood substitutes: perfluorocarbons and hemoglobin-based oxygen carriers. METHODS We provide a review of the notable products developed in both categories and include their attributes as well as their setbacks. RESULTS We contribute a case report tothe growing literature of the successful use of Sanguinate. CONCLUSIONS We find that artificial oxygen carriers are an attractive field of research because of the practical limitations and the multitude of potential complications that surround human blood transfusions.
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Affiliation(s)
- Sara Emily Bachert
- Department of Pathology and Laboratory Medicine, University of of Kentucky Medical Center, Lexington
| | - Prerna Dogra
- Department of Medicine, University of Kentucky, Lexington
| | - Leonard I Boral
- Department of Pathology and Laboratory Medicine, University of of Kentucky Medical Center, Lexington
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4
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Zantek ND, Pagano MB, Rollins-Raval MA, Smith RE, Schmidt AE, Crane JE, Boral LI, Li Y, Svensson AM, Yamada C, Wu Y, Wong ECC. Hemostasis testing and therapeutic plasma exchange: Results of a practice survey. J Clin Apher 2018; 34:26-32. [DOI: 10.1002/jca.21666] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 07/31/2018] [Accepted: 09/03/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Nicole D. Zantek
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Monica B. Pagano
- Department of Laboratory Medicine; University of Washington; Seattle Washington
| | - Marian A. Rollins-Raval
- Department of Pathology and Laboratory Medicine; University of North Carolina; Chapel Hill North Carolina
| | - Roy E. Smith
- Hematology/Oncology Division; University of Pittsburgh Medical Center Presbyterian-Shadyside Hospital; Pittsburgh Pennsylvania
| | - Amy E. Schmidt
- Department of Pathology and Laboratory Medicine; University of Rochester Medical Center; Rochester New York
| | | | - Leonard I. Boral
- Department of Pathology and Laboratory Medicine; University of Kentucky; Lexington Kentucky
| | - Yanhua Li
- Department of Pathology and Laboratory Medicine; New York University; New York New York
| | | | - Chisa Yamada
- Department of Pathology; University of Michigan; Ann Arbor Michigan
| | | | - Edward C. C. Wong
- Department of Coagulation; Quest Diagnostics Nichols Institute; Virginia
- Departments of Pediatrics and Pathology; George Washington School of Medicine and Health Sciences; Washington DC
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5
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Zantek ND, Boral LI, Li Y, Yamada C, Svensson AM, Crane JE, Smith RE, Pagano MB, Rollins-Raval MA, Schmidt AE, Wong ECC, Wu Y. Hemostasis management and therapeutic plasma exchange: Results of a practice survey. J Clin Apher 2018; 33:604-610. [DOI: 10.1002/jca.21653] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 05/31/2018] [Accepted: 07/12/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Nicole D. Zantek
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Leonard I. Boral
- Department of Pathology and Laboratory Medicine; University of Kentucky; Lexington Kentucky
| | - Yanhua Li
- Department of Pathology and Laboratory Medicine; New York University; New York New York
| | - Chisa Yamada
- Department of Pathology; University of Michigan; Ann Arbor Michigan
| | | | | | - Roy E. Smith
- Hematology/Oncology Division; University of Pittsburgh Medical Center Presbyterian-Shadyside Hospital; Pittsburgh Pennsylvania
| | - Monica B. Pagano
- Department of Laboratory Medicine; University of Washington; Seattle Western Australia
| | - Marian A. Rollins-Raval
- Department of Pathology and Laboratory Medicine; University of North Carolina; Chapel Hill North Carolina
| | - Amy E. Schmidt
- Department of Pathology and Laboratory Medicine; University of Rochester Medical Center; Rochester New York
| | - Edward C. C. Wong
- Department of Coagulation; Quest Diagnostics Nichols Institute; Virginia
- Departments of Pediatrics and Pathology, George Washington School of Medicine and Health Sciences; Washington DC
| | - Yanyun Wu
- Bloodworks; Seattle Western Australia
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6
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Abstract
OBJECTIVES To provide a review of the definition, pathophysiology, differential diagnosis, and treatment of disseminated intravascular coagulation (DIC). METHODS A case scenario and a review of the literature related to the pertinent facts concerning DIC are provided. RESULTS DIC is a systemic pathophysiologic process and not a single disease entity, resulting from an overwhelming activation of coagulation that consumes platelets and coagulation factors and causes microvascular fibrin thrombi, which can result in multiorgan dysfunction syndrome from tissue ischemia. Some conditions associated with acute DIC include septic shock, exsanguinating trauma, burns, or acute promyelocytic leukemia. CONCLUSIONS The massive tissue factor stimulus results in excess intravascular thrombin, which overcomes the anticoagulant systems and leads to thrombosis. Because of consumption of coagulation factors and platelets, DIC also has a hemorrhagic phase. Treatment of the bleeding patient with DIC is supportive with the use of blood components.
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Affiliation(s)
| | - Dennis J Williams
- Pathology and Laboratory MedicineUniversity of Kentucky Medical Center, Lexington
| | - Leonard I Boral
- Pathology and Laboratory MedicineUniversity of Kentucky Medical Center, Lexington
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7
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Boral LI, Bernard A, Hjorth T, Davenport D, Zhang D, MacIvor DC. How do I implement a more restrictive transfusion trigger of hemoglobin level of 7 g/dL at my hospital? Transfusion 2015; 55:937-45. [DOI: 10.1111/trf.12982] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 11/14/2014] [Accepted: 11/14/2014] [Indexed: 01/28/2023]
Affiliation(s)
- Leonard I. Boral
- Department of Pathology and Laboratory Medicine; UK College of Medicine; Lexington Kentucky
| | - Andrew Bernard
- Department of Surgery; UK College of Medicine; Lexington Kentucky
| | - Todd Hjorth
- Finance Department; UK Healthcare; University of Kentucky; Lexington Kentucky
| | - Daniel Davenport
- Department of Surgery; UK College of Medicine; Lexington Kentucky
| | - Daoping Zhang
- Department of Pathology and Laboratory Medicine; UK College of Medicine; Lexington Kentucky
| | - Duncan C. MacIvor
- Department of Pathology and Laboratory Medicine; UK College of Medicine; Lexington Kentucky
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8
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Boral LI, Staubach ZG, de Leeuw R, MacIvor DC, Kryscio R, Bada HS. Comparison of outcomes of group O vs non-group O premature neonates receiving group O RBC transfusions. Am J Clin Pathol 2013; 140:780-6. [PMID: 24225743 DOI: 10.1309/ajcpjx94spzlqlgg] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES At some institutions all infants requiring RBC transfusions in neonatal intensive care units (NICUs) receive only group O RBCs. Although transfused group O plasma is minimized in packed RBCs, small amounts of residual anti-A, anti-B, and anti-A,B in group O packed RBCs may bind to the corresponding A and B antigens of non-group O RBCs, possibly hemolyzing their native RBCs and thereby releasing free hemoglobin, theoretically resulting in hypercoagulability and promoting bacterial growth from free iron. METHODS Premature infants in the University of Kentucky Children's Hospital NICU database who were transfused (all received group O transfusions) were compared for a number of severity markers to determine if non-group O patients had worse outcomes than group O patients. RESULTS In this NICU sample, 724 neonates received at least 1 blood component. No significant differences were found between group O and non-group O infants with regard to final disposition or complications. CONCLUSIONS This reassuring finding validates the longstanding neonatal transfusion practice of using group O packed RBCs for infants of all blood groups in the NICU. However, a recent study shows increased mortality from necrotizing enterocolitis in group AB neonates at a facility transfusing only group O RBCs to neonates of all blood groups and suggests a change in neonatal transfusion practice to ABO group-specific RBCs; therefore more studies may be warranted.
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Affiliation(s)
- Leonard I. Boral
- Departments of Pathology and Laboratory Medicine, University of Kentucky Medical Center, Lexington, KY
| | - Zane G. Staubach
- College of Medicine, University of Kentucky Medical Center, Lexington, KY
| | - Reny de Leeuw
- Division of Orofacial Pain, University of Kentucky Medical Center, Lexington, KY
| | - Duncan C. MacIvor
- Departments of Pathology and Laboratory Medicine, University of Kentucky Medical Center, Lexington, KY
| | - Richard Kryscio
- Division of Biostatistics, University of Kentucky Medical Center, Lexington, KY
| | - Henrietta S. Bada
- Division of Neonatology, University of Kentucky Medical Center, Lexington, KY
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9
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Sutton GP, Jay A, Lim YS, Noland JE, Boral LI. The use of Rh immune globulin: a review. Indiana Med 1988; 81:321-2. [PMID: 2834434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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10
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Lamberson RD, Boral LI, Berry-Dortch S. Limitations of the crossmatch for detection of incompatibility between A2B red blood cells and B patient sera. Am J Clin Pathol 1986; 86:511-3. [PMID: 3766464 DOI: 10.1093/ajcp/86.4.511] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
A recent evaluation of the immediate-spin crossmatch has revealed limitations when used for the detection of ABO incompatibilities in tests between group B patient sera and group A2B donor red blood cells. Presented with the option of deleting the anti-globulin crossmatch, the study reported here was conducted to determine whether the anti-globulin crossmatch would detect the ABO incompatibilities missed by the immediate spin. Results of 1,000 crossmatches between group B patient sera and group A2B red blood cells showed that the anti-globulin phase was capable of detecting a higher percentage of incompatibilities than the immediate-spin procedure, 79.4-86.8% versus 40-64.4%, respectively, depending on the enhancement used. Although anti-globulin testing did detect a substantially higher number of incompatibilities, are the increased cost of reagents and technologists' time used in performing the anti-globulin crossmatch justified for the detection of ABO incompatibilities? Due to limitations observed with the anti-globulin test in addition to budgetary and fiscal constraints, retention of the anti-globulin testing purely for ABO compatibility is not warranted.
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11
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Boral LI. Survey of blood transfusion practices in Indiana. Indiana Med 1986; 79:621-7. [PMID: 3745898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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12
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13
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Abstract
In the eleventh edition of the AABB's Standards for Blood Banks and Transfusion Services the requirement for an antiglobulin crossmatch was deleted if no clinically significant unexpected antibodies are detected in recipient serum testing and if there is no history of detection of such antibodies. Test methods that demonstrate ABO incompatibility remain a requirement; however, the means to accomplish this may prove controversial. The immediate spin crossmatch has been used for the purpose of detecting ABO incompatibility by many workers. Nonetheless, limitations of this technique became apparent in tests between A2B donor red cells and group B patient sera. The results of 204 of 531 immediate spin crossmatches, between these two blood groups, were found to be negative.
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14
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15
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Mintz PD, Henry JB, Boral LI. The type and antibody screen. Clin Lab Med 1982; 2:169-79. [PMID: 7186425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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16
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Boral LI, Hill SS. The Authors’ Reply. Am J Clin Pathol 1980. [DOI: 10.1093/ajcp/73.5.731a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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17
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Boral LI, Dannemiller FJ, Stanford W, Hill SS, Cornell TA. A guideline for anticipated blood usage during elective surgical procedures. Am J Clin Pathol 1979; 71:680-4. [PMID: 110135 DOI: 10.1093/ajcp/71.6.680] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
A realistic guideline for transfusion therapy was prepared, with the cooperation of the departments of anesthesiology and surgery, in order to reduce excessive crossmatching. The guideline recommends an ABO-Rh type and an antibody screen, instead of the ""routine'' two-unit crossmatch, for elective surgical procedures where blood is seldom used. For those operations normally necessitating hemotherapy, the number of units suggested for the preoperative crossmatch was determined by examination of the average number of units transfused in the past for that particular procedure. The guideline provides the anesthesiologic and surgical staff with the knowledge of how much blood was usually used during a particular elective surgical procedure and therefore how much blood should be preoperatively crossmatched for that procedure. Implementation of this guideline allows the blood bank to distribute its limited blood resources more efficiently and also decreases patient and laboratory costs.
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Abstract
The type and antibody screen is a safe, economical substitute for "routine" two-unit crossmatch in those elective surgical procedures rarely necessitating blood transfusion. This report confirms a previous finding that the type and antibody screen is 99.99% effective in preventing the transfusion of incompatible blood. The type and antibody screen is even safer than the stated 99.99%, when the immediate spin, saline and albumin procedures (the initial portion of the authors' complete crossmatch) are performed prior to releasing blood in an emergency situation. The immediate spin procedures not only verify the ABO compatibility but also detect any high-titer antibodies directed against low-incidence antigens that might not have been present on the screening reagent erythrocytes. The use of the type and antibody screen is applicable only in those medical facilities that have moderate reserves of blood readily available for transfusion.
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Henry JB, Boral LI, Mintz PD. Abbreviated major crossmatch. Transfusion 1978; 18:765-6. [PMID: 726027 DOI: 10.1046/j.1537-2995.1978.18679077966.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Abstract
Eighty-one patients have been followed in our ambulatory transfusion clinic for a total of 176 patient visits. They received phlebotomies, plasmapheresis, and transfusions of erythrocytes and platelets. Minor reactions (febrile reactions, transient hypotension, and urticaria) occurred in only six patients. The advantages of a transfusion service conducted by blood bank professional and technical staff are numerous. The nurse/patient ratio is low enough so that the patient can receive individualized attention including virtually constant vigilance. The laboratory staff and pathologist become familiar with the therapeutic management of patients who may potentially place great stress on the laboratory. The transfusion clinic also provides an opportunity for the pathologist to gain further experience and to train others as transfusion therapists, a role which he is often asked to assume when a transfusion reaction occurs. The gain for the outpatient clinic and emergency room is that they can function more efficiently when more rooms are available for patients who have a faster turnover time.
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Abstract
For the year 1975, we examined 12,848 blood specimens using the type and screen as well as the crossmatch and detected 283 antibodies in 247 patients. Our screening reagent red blood cells were able to detect 96.11 per cent of these antibodies. If the antigen frequencies corresponding to those antibodies not detectable by our screening reagent red blood cells are taken into consideration. i.e., the incompatibility frequencies, the type and screen can be shown to be 99.99 per cent effective in preventing the transfusion of incompatible blood. Therefore, we believe that the type and screen may be safey substituted for the routine two-unit crossmatch in those operative procedures usually not requiring transfusions. Adoption of this approach would reduce patient charges, provide for more efficient distribution of our limited blood supplies, and allow for more effective utilization of blood-bank technologist time.
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Davey FR, Gordon GB, Boral LI, Gottlieb AJ. Gamma globulin inhibition of fibrin clot formation. Ann Clin Lab Sci 1976; 6:72-7. [PMID: 1247286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Myeloma gamma globulins have been reported to interfere with fibrinogen-fibrin conversion. A patient with multiple myeloma is described with a gamma globulin IgG1lambda concentration of 11 g per dl, prolonged thrombin time and poor clot retraction. Purified gamma globulin from the patient's serum and from normal serum caused prolongation of the thrombin time and reptilase clotting time assays in both normal plasma and in solutions of bovine fibrinogen. In addition, fibrin clots formed during the thrombin time assays were found to be ultrastructurally abnormal. This data suggests that the interaction of gamma globulin in the polymerization of fibrin may, in at least some cases, be due to nonspecific protein interaction.
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