Audit and education in transfusion medicine

Because transfusions carry risks to the patient and because inappropriate transfusions are costly, interest in audits and effective education in transfusion medicine has increased over the last decade. Audits identify areas of practice that can be improved by follow-up education of the physicians who prescribe the transfusions. Successful educational approaches to follow-up on problems identified by audit include 30-min one-on-one meetings with surgeons, traditional scheduled teaching conferences, daily clinical rounds on transfused patients, prospective review of blood transfusions and installation of transfusion practice algorithms in the operating room. Other than identifying inappropriate transfusions, audit and education have also been used successfully to improve bedside blood administration practices, decrease unnecessary crossmatches and reduce outdating of donor blood. Multi-institutional audits play a useful benchmarking role. In summary, audit followed by targeted education can improve practices in transfusion medicine.

Physician recommendation as the key factor in patients' decisions to participate in preoperative autologous blood donation programs: Preoperative Autologous Blood Donation Study Group

To determine whether the physician or patient had initiated the discussion regarding preoperative autologous blood donation (PABD) and to assess the relative importance of the physician's recommendation in patients' decision to donate, responses were obtained from 254 of 409 patients (62%) who had donated preoperatively during the 3 study months. Nearly all (96%) strongly agreed they would donate again for themselves and nearly all (94%) strongly agreed they would recommend PABD to others. Patients initiated the discussion about PABD 23% of the time, while 71% indicated strong surgeon input. The remaining respondents said their surgeon had "mentioned it, but said it was up to me." The importance of avoiding transfusion reactions was rated significantly greater among those whose surgeons had initiated the discussion, as was the relative weight of the surgeon's recommendation. The desire to alleviate the blood shortage was rated much less important among patients who had initiated the discussion themselves.

Effectiveness of transfusion audits and practice guidelines

To seek evidence of the effectiveness of transfusion audits and practice guidelines in improving transfusion practice, transfusion audit literature was reviewed. The inherent limitation of this approach is that investigators are more likely to report success and less likely to report unsuccessful experiences. Measures of success included decrease in units transfused, decrease in inappropriate units transfused, or increase in appropriate transfusion practice. Side benefits of audits included continuous improvement in practice guidelines, improvement in technologists' education, opportunities for consultation, and identification of areas for further research. Most successful programs had a common thread: individual education of the ordering physician by the transfusion medicine physician. In addition, for most successful programs, audits occurred in a timely manner, either before transfusion or during the 24 hours or weekend after the transfusion. In conclusion, several reports provide corroborating evidence to suggest that transfusion audits can improve transfusion practice if performed in a timely manner and if individual education of ordering physicians is provided by transfusion medicine physicians.

Efficacy of preoperative donation of blood for autologous use in radical prostatectomy

To determine the amount of blood lost, the number of transfusions, and the effectiveness of preoperative autologous blood donation in radical prostatectomy, 163 patients' records from 1987 to 1991 were reviewed at four university hospitals and three community hospitals. Calculated red cell volume lost was 1003 +/- 535 mL (mean +/- SD), which corresponds to 44 +/- 18 percent (mean +/- SD) of total red cell volume. Preoperative donation of blood for autologous use reduced the rate of transfusion of allogeneic blood from 66 to 20 percent (p < 0.001). Of the patients who donated 1 to 2 units, 32 percent received allogeneic blood; 14 percent of those who donated 3 units received allogeneic blood. Donation of 4 units reduced the allogeneic transfusion rate to 11 percent. However, as the number of units donated increased (1-3 units), the units not transfused also increased (0-21%). Ninety-one (56%) of 163 patients donated fewer than 3 units. Autologous blood donation is effective in minimizing the transfusion of allogeneic blood to radical prostatectomy patients, but many patients do not donate enough blood (< 3 units). The donation of 3 units of blood for autologous use is recommended for patients who undergo radical prostatectomy.

Prospects for control of hepatitis B virus infection: implications of childhood vaccination and long-term protection

Hepatitis B vaccine has been recommended for high-risk individuals in the United States for more than a decade. This targeted strategy, however, has failed to control hepatitis B virus (HBV) infection. Universal immunization is being considered as an alternative approach, in particular the inclusion of hepatitis B vaccine with routine childhood vaccinations. Data presented herein demonstrate a high degree of efficacy for hepatitis vaccine with hepatitis B immune globulin in preventing perinatal HBV infection in newborns. Immune response to vaccine was dependent in part on the dose administered, with some enhancement of response if the infant was older at the time of initial injection or if the booster dose was given later. Long-term follow-up showed persistence of vaccine-induced antibody for 5 to 10 years in 90% of immunized infants and adults. Only 3% to 5% of these high-risk individuals had serologic evidence of an HBV infection. None of the infections had been symptomatic and none resulted in a chronic HBV carrier state. Thus, immune responses and efficacy of hepatitis B vaccine in infants were excellent, and immunity and protection against clinically significant HBV infection persisted for at least 5 to 10 years, features essential to success of a program of universal childhood immunization against HBV.

Improvement in appropriate autologous donations with local education: 1987 to 1989

Preoperative autologous blood donation for elective surgery patients at university hospitals was underused in the past. More recently, national educational efforts have been made. To test the impact of local surgeon interviews and education, in 1988 the same local educational program was instituted at three university hospitals; three community hospitals were used as controls. Donation by appropriate patients of interviewed surgeons (elective surgery, crossmatch recommended, no contraindications to donation) increased from 24 percent (44/180) to 40 percent (88/222) (p = 0.002) and 15 percent (21/143) to 32 percent (41/127) (p = 0.001) at two university hospitals where the investigator-educators were on site, but not at the three community hospitals. Between 1987 and 1989, donation rates at all six hospitals remained low among patients for whom autologous donation was (probably) less appropriate. Donation rates for type and screen procedures were 3.0 percent (131/4587) in 1987 and 3.0 percent (199/6606) in 1989 (p = 0.67). Donation rates for "no blood order" procedures were 0.2 percent (15/9429) in 1987 and 0.1 percent (9/11,239) in 1989 (p = 0.14). It can be concluded that appropriate autologous blood donations increased at university hospitals where surgeons were individually interviewed and educated by an investigator on site. However, despite this increase, apparently eligible elective surgery patients in 1989 still failed to donate. This situation deserves additional investigation.

Factors associated with successful autologous blood donation for elective surgery

Not all donors can donate the number of autologous blood units requested by their physicians before surgery, and donors are more frequently unsuccessful as more units are requested. Therefore, 368 autologous blood donors who were requested to donate 4 or more units during the 6-week period before surgery at one community blood center were studied. More men were able to donate 4 units with no deferrals for anemia than were women (86% [181 of 211] compared to 42% [48 of 115], P less than 0.001). Greater success also was observed among donors with an initial hemoglobin level greater than 125 g/L (12.5 g/dL), those with higher weight, and those with more advanced age. Multiple logistic regression analysis showed that only higher initial hemoglobin levels (odds ratio, 3.3 per 10 g/L [1 g/dL] increment) and male sex (odds ratio, 2.7) were independent predictors of successful donation of 4 or more units.

Blood loss and replacement in total hip arthroplasty: a multicenter study. The Preoperative Autologous Blood Donation Study Group

To determine blood loss, the number of transfusions, and the hemoglobin levels achieved in patients via transfusion in the course of total hip arthroplasty, 324 patient records from 1987 through 1989 were reviewed at three university and three community hospitals. Calculated blood loss was 3.2 +/- 1.3 units in primary procedures and 4.0 +/- 2.1 units in revision procedures (mean +/- SD). Of 777 red cell units transfused, 455 (59%) were autologous units. Transfused patients received 2.0 +/- 1.8 units for primary procedures and 2.9 +/- 2.3 units for revision procedures (mean +/- SD). The maximum number of units given to 95 percent of the transfused patients was 4 for primary procedures and 6 for revision procedures. The mean postoperative hemoglobin level after all transfusions was 103 to 110 g per L, regardless of patient age group of physical status, autologous donor status, or hospital. No difference in length of hospital stay was observed for patients less than 65 years old with hemoglobin concentrations of 80 to 139 g per L at discharge.

Laboratory hemostatic abnormalities in massively transfused patients given red blood cells and crystalloid

Most of the literature on massive transfusion concerns whole blood replacement, whereas clinically, packed red blood cells are commonly given. To determine when hemostatic abnormalities occur in patients resuscitated primarily with packed red blood cells and crystalloid, the cases of 39 consecutive patients who were transfused with 10 or more red blood cell units of any kind within 24 hours were reviewed. After transfusion with 20 or more units of red blood cell products of any kind (packed red blood cells, cell-saver units, or whole blood), 75% (3 of 4) of patients had platelet counts less than 50 x 10(9)/L, compared to 0 of 29 patients given less than 20 units (P less than 0.001). After transfusion of 12 units of relatively plasma-free red blood cell products (packed red blood cells or cell-saver units), 100% (8 of 8) of patients had prothrombin time prolonged by more than 1.5 times mid-range of normal, compared to 36% (5 of 14) of patients given less than 12 units (P = 0.012). These data confirm that patients massively transfused with red blood cells of any kind develop significant thrombocytopenia after 20 units. Importantly, probably clinically significant prothrombin time and partial thromboplastin time prolongations occurred consistently after transfusion of 12 units of relatively plasma-free red blood cells in unselected patients at an urban trauma hospital. These data suggest that coagulation factor replacement is necessary in patients who receive 12 or more units of packed red blood cells or cell-saver blood, and platelet replacement is necessary in patients who receive 20 or more units of any red blood cell product. A prospective study is needed to determine whether the expected abnormal clinical bleeding indeed occurs in patients with such laboratory coagulation abnormalities and to determine when plasma transfusion is indicated in patients massively transfused with red blood cells.

Probable reasons that autologous blood was not donated by patients having surgery for which crossmatched blood was ordered

Preoperative autologous blood donation is used by only a small percentage of surgery patients for whom crossmatched blood is ordered. To document the reasons the patients failed to donate, the medical records of surgical patients at three university and three community hospitals were studied. All procedures for which crossmatched blood was ordered, but for which autologous blood was not available, were included (n = 8121). Probable reasons for nondonation were found in 72 percent of university hospital patients and 65 percent of community hospital patients (n = 6064 and n = 2057, respectively). The most frequent reasons for nondonation among university hospital patients were emergency surgery (27%) and age less than 12 years (17%), and those among community hospital patients were emergency surgery (42%) and American Society of Anesthesiologists physical status greater than or equal to 4 (20%). Surprisingly, anemia (hemoglobin less than 11 g/dL [less than 110 g/L]) as the only limitation to donation was rarely found: this was the sole reason in only 3.3 percent of university hospital and 4.5 percent of community hospital patients. Overall, of 8121 patients who failed to donate autologous blood, 5731 (71%) had legitimate medical reasons. The remaining 2390 (29%) had no identifiable reason for nondonation, and recruitment efforts should be focused on them and their surgeons.

Donor room personnel attitudes toward autologous donors

Patients with serious illnesses who donate their blood for autologous use create anxiety for many phlebotomists. Donor room staff were surveyed at three donor centers, using confidential questionnaires, to identify their concerns and to evaluate factors associated with reduced anxiety toward autologous donors. Among respondents (n = 93), 58 percent had patient care experience within the last 5 years, which correlated with diminished concern about phlebotomizing cardiac patients (r = .21; p = 0.04). Fifty-seven percent of respondents had drawn blood from greater than 50 autologous donors. Surprisingly, the experience of drawing blood from relatively large numbers of autologous donors did not correlate with increased confidence in phlebotomizing pediatric, cardiac, and elderly patients (r = -.04; p = 0.75). Those respondents who felt that they had adequate medical support agreed with more liberal donor criteria and were more confident about phlebotomizing pediatric, cardiac, and elderly patients (r = -.32; p = 0.001). Those respondents who believed most strongly in the benefits of autologous transfusion had the least anxiety toward donors who were medically more complex (r = .39; p = 0.0001). It is concluded that, contrary to what might be expected, phlebotomizing large numbers of autologous donors does not reduce the anxiety of staff members when they encounter donors with complex medical problems. Factors that do reduce anxiety include dependable physician and other medical support services, previous experience in direct patient care, and knowledge of the benefits of autologous transfusion.

Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities

To determine whether untreated mild coagulopathy in patients with no evidence of clinical bleeding is associated with an increased risk of hemorrhage after paracentesis or thoracentesis, retrospective examination was conducted of 608 consecutive procedures for which prothrombin time (PT), partial thromboplastin time (PTT), platelet (Plt) counts, and preprocedure and postprocedure hemoglobin concentrations were available. There was no increased bleeding in patients with mild to moderate coagulopathy (defined as PT or PTT up to twice the midpoint normal range or pit count of 50 to 99 x 10(3) per microL [50-99 x 10(9)/L]). However, patients with markedly elevated serum creatinine levels (6.0 to 14.0 mg/dL [530-1240 mumol/L]) had a significantly greater average hemoglobin loss (-0.82 +/- 1.3 g/dL [-8 +/- 13 g/L], n = 11) than patients with normal serum creatinine levels (-0.12 +/- 0.88 g/dL [-1 +/- 9 g/L], n = 450) (p = 0.011). Overall, the frequency of bleeding complications requiring red cell transfusions was very low: 0.2 percent of events. The most common diagnosis for patients who had paracentesis was alcoholic liver disease (72%); for those having thoracentesis, it was infection (37%). It can be concluded that, for these patients, prophylactic plasma or platelet transfusions are not necessary. Patients with markedly elevated serum creatinine deserve close postprocedure observation.

Return of autologous blood donors as homologous blood donors

Autologous blood donors (ABDs) have been reported to have favorable attitudes toward returning as homologous blood donors (HBDs), but the frequency of return has not been well documented. ABDs eligible by history to be HBDs were followed at one blood center: 255 donating for elective surgery and 234 donating during pregnancy were followed for an average of 18 months and 20 months, respectively, from time of eligibility after surgery or postpartum. Male ABDs had a higher rate of return as HBDs, as 34 percent (21/62) returned to donate an average of 3 units, whereas 13 percent (56/427) of female ABDs returned as HBDs to donate an average of 2 units. Although a history of donation was associated with a higher rate of return (30%, 34/113), 11 percent (43/376) of ABDs with no history as HBDs returned to donate homologous units, despite having been recruited less frequently than prior HBDs. Overall, all male ABDs and female ABDs with an HBD history returned most frequently. The extra effort required for an autologous donor program may result in the recruitment of new donors into the HBD pool.

The variability of transfusion practice in coronary artery bypass surgery. Transfusion Medicine Academic Award Group

We audited 540 patients undergoing elective first-time coronary artery bypass grafts at 18 institutions. The purposes of the study were to describe the variability in transfusions among institutions and to determine factors that may account for variability. Mean homologous red blood cell use per patient was 2.9(+/- 0.1) U (institutional range, 0.4 to 6.3 U). One hundred seventy-seven patients (32%) received plasma (institutional range, 0% to 97%), and 119 (22%) received platelets (institutional range, 0% to 80%). After controlling for patient and surgical practice variables, transfusion practice factors still accounted for variation in red blood cell transfusions. Variation in patients receiving plasma and platelet transfusions among institutions was determined in part by prophylactic transfusions. We conclude that blood component usage for coronary artery bypass grafts differs widely among institutions. The variability in use of these components is accounted for in part by unnecessary transfusions in otherwise routine, uncomplicated coronary artery bypass graft procedures.

Lack of increased bleeding after liver biopsy in patients with mild hemostatic abnormalities

Prophylactic transfusions of fresh frozen plasma and platelets are sometimes given to patients with mild elevations in prothrombin time (PT) and partial thromboplastin time (PTT) and mild thrombocytopenia before percutaneous liver biopsy. To determine whether PTs and PTTs 1.1-1.5 times midrange normal levels and platelet counts 50-99 x 10(9)/L are associated with increased bleeding complications, hospital records of all patients who underwent percutaneous liver biopsy during 56 consecutive months (n = 291) were reviewed. Complete information was available for 177 inpatient procedures (155 standard, 22 fine needle). Overall, the frequency of bleeding complications in patients with platelet counts greater than or equal to 50 X 10(9)/L was 3.4% (6 of 175), with no significant difference between patients with mild hemostatic abnormalities and patients with normal parameters. These data suggest that prophylactic transfusions may not be necessary. One factor was highly associated with bleeding complications: a patient diagnosis of malignancy, 14% (7 of 50) compared with 0.8% (1 of 127) among other patients (P less than 0.001). These patients should be monitored closely after biopsy.

Moderate and severe reactions during autologous blood donations are no more frequent than during homologous blood donations

Because autologous donation is permitted for donors who do not meet homologous blood donation standards, referring physicians and blood center personnel may be concerned about autologous donor reactions. Small studies have determined that mild reactions do not occur more frequently, but the incidence of rarer, more serious, moderate and severe reactions is unknown. We therefore studied the frequency of reactions during 10,200 autologous and 219,307 concurrent homologous donations at four blood centers. No significant difference was seen for severe reactions: autologous 0.039% (4/10,200), homologous 0.037% (82/219,307) (p = 0.79); moderate reactions: autologous 0.19% (19/10,200), homologous 0.22% (473/219,307) (p = 0.60) or mild reactions: autologous 2.26% (231/10,200), homologous 2.26% (4946/219,307) (p = 0.98). We conclude moderate and severe donation reactions do not occur more frequently among autologous donors who are preselected by referring physicians and screened by blood center personnel.

Surgeons' knowledge, attitude, and use of preoperative autologous blood donation

Before a comprehensive educational program on preoperative autologous blood donation was begun, 118 surgeons from three different areas of the country were tested to assess their baseline knowledge and attitude about this practice. Test results were correlated with the percentage of eligible patients that the surgeons actually referred for preoperative donation during a period of observation. The purpose of this preliminary effort was to identify areas in the educational program that required emphasis. Overall, the surgeons' attitude toward preoperative donation was quite favorable, but their depth of knowledge varied. Misunderstandings may have led to diminished use of this service (eg, about 50% didn't realize that many patients with medical conditions or low hematocrits are permitted to donate). However, it is not clear that simply bolstering surgeons' knowledge will increase their appropriate use of preoperative donation. When all 118 surgeons were studied, their knowledge and attitude were unrelated to the percentage of eligible patients referred. However, when 44 surgeons who managed the largest number of eligible patients were analyzed separately, their use of preoperative donation was directly correlated with their knowledge and attitude. The local awareness of AIDS also significantly influenced the use of this service. It is proposed that knowledge of preoperative donation may be important for inducing surgeons to begin referring patients for this service. Once a pattern of successful participation is established, referral seems to increase with the acquisition of working knowledge.

Agglutination of red blood cells from patients with diabetes mellitus by a polyclonal human antibody specific for D-glucose

We have previously described an antibody which will agglutinate red blood cells which had been incubated in vitro in D-glucose. This antibody is specific for the ring form of glucose, beta-D-glucopyranose. The current report demonstrates that without prior in vitro incubation with glucose, red blood cells from 36 of 38 patients with diabetes mellitus, and 7 of 70 patients not diagnosed as diabetic were agglutinated by this antibody. Strength of agglutination of red blood cells from diabetic patients correlated with both glucose (r = 0.61; p less than 0.001) and hemoglobin A1c levels (r = 0.50; p less than 0.01) in simultaneously obtained samples. This reactivity could be reversed by incubating red blood cells from diabetics for several hours in saline. This report suggests that red blood cells from diabetic patients have membrane-bound glucose that can be detected immunologically. Reversibility of the reaction and rapidity of in vitro glycosylation suggests short-term binding of glucose. To our knowledge, this is the first report documenting immunological detection of in vivo short-term reversible binding of glucose to cellular membranes.

Donation reactions among autologous donors

Studies of risk factors associated with reactions among autologous blood donors have been limited. Therefore, 2091 autologous and 4737 homologous donations were examined. Donors at greatest risk for reaction were autologous donors who had reactions at first donation; among 45 who made repeat donations for the same surgery, 17 (38%) had repeat reactions. The group least likely to experience reactions were the autologous donors greater than or equal to 66 years old; they experienced a 1.9 greater than or equal to percent (6/310) incidence of reactions. More reactions were seen in both autologous and homologous donors in the categories of first-time donor, female gender, decreasing age, and lower weight. Multiple logistic regression analysis showed that all of these variables were independent predictors of donor reaction, with first-time donation (odds ratio, 2.4) and female gender (odds ratio, 1.9) being the strongest predictors of reaction. Donor room personnel should be alerted that autologous donors who react at first donation are very likely to react at subsequent donations. Contrary to common concern, elderly autologous donors are least likely to have reactions.

Red cell transfusion therapy for anemia in patients with AIDS and ARC: incidence, associated factors, and outcome

The records of the San Francisco General Hospital (SFGH) Blood Bank were reviewed, and 263 likely AIDS and AIDS-related complex (ARC) patients were identified, who received 1545 units of packed red cells (PBRCs) between July 1, 1987, and June 30, 1988. A probability sample of 80 of these patients was selected randomly for detailed chart review. Of this sample, 78 (98%) were confirmed to have AIDS (86%) or ARC (14%). On the basis of the yearly census of the SFGH AIDS clinic, a transfusion incidence of 0.89 PRBC units per patient per year for patients with AIDS and 0.27 PRBC units per patient per year for those with ARC was estimated. Whereas 26 percent of the 177 transfusions studied in detail involved more than one associated (possibly causative) factor, antimicrobial drug therapy, zidovudine therapy, and disseminated Mycobacterium avium complex (MAC) infection were the sole associated factors in 20, 14, and 12 percent of the transfusions, respectively. To assess the role of MAC, the 263 transfused patients were compared with the 574 patients whose blood was submitted to the SFGH Mycobacteriology Laboratory during the same period. Patients whose blood yielded MAC had a relative risk of 5.2 for transfusion-requiring anemia. In 80 percent of cases, the patient returned home after transfusion. Most PRBC transfusions administered to AIDS or ARC patients were optimal therapy.

Safety and use of autologous blood donation during the third trimester of pregnancy

To examine autologous blood donation during the third trimester of pregnancy, records of 272 blood donors who donated by standard procedures were reviewed. The incidence of vasovagal reactions at autologous donation was 2.1% (7/341) versus 1.1% (1370/121,539) at homologous donation (p = 0.17). Follow-up was available for 199 of these donors and 10 additional donors with fetal monitoring. Infant morbidity and mortality rates were not higher than expected; 0.5% (1/214) was stillborn. Although 11% (24/209) of deliveries was associated with autologous transfusion, only 4.3% (9/209) would have had a hemoglobin level less than 8 gm/dl without transfusion. Patients with placenta previa had the highest incidence of transfusion, 83% (5/6). Transfusion incidence was higher for women donating within 1 week of delivery, 21% (8/38), versus 9.4% (16/171) for women donating earlier in pregnancy (p = 0.044). We recommend that donation be completed by 2 weeks before the estimated date of confinement to allow for recovery of red cell mass.

Prevalence of ABO maternal-infant incompatibility in Asians, Blacks, Hispanics and Caucasians

Previous studies suggest that race is a risk factor in ABO hemolytic disease of the newborn (ABO-HDN). In order to compare the prevalence of ABO-HDN in Asian, Black, Hispanic and Caucasian infants, we studied 10,611 consecutive births at one hospital over a 6-year period. Among group A infants born to group O mothers, the prevalence of positive DAT differed among the four groups (p = 0.007), and was highest in Asians (50%) and lowest in Caucasians (31%). However, the proportions of infants who required exchange transfusion were not different (p = 0.351). Among group B infants born to group O mothers, the prevalence of positive DAT was not different among the four groups (p = 0.26) and none of these 166 group B infants with a positive DAT result required exchange transfusion. Our findings suggest that there are small ethnic differences in the prevalence of positive DAT results in group A infants born to group O mothers, but the prevalence of clinical disease which requires exchange transfusion does not differ significantly among Asian, Black, Hispanic and Caucasian infants.

Oxygen-induced marrow red cell hypoplasia leading to transfusion in sickle painful crisis

The benefit of oxygen (O2) therapy in non-hypoxic sickle cell patients in painful crisis is uncertain. We report a case of a non-hypoxic sickle cell patient in painful crisis who developed marrow red cell hypoplasia requiring transfusion support after O2 therapy. The uncertain benefits of O2 use in such cases must be weighed against the serious and underrecognized risks of transfusion. In patients who develop O2-induced marrow red cell hypoplasia, cessation of O2 therapy may reverse the anemia and obviate the need for transfusion.

Yeast-recombinant hepatitis B vaccine. Efficacy with hepatitis B immune globulin in prevention of perinatal hepatitis B virus transmission

A yeast-recombinant hepatitis B vaccine was licensed recently by the Food and Drug Administration and is now available. To assess the efficacy of the yeast-recombinant vaccine, we administered the vaccine in combination with hepatitis B immune globulin to high-risk newborns. If infants whose mothers were positive for both hepatitis B surface antigen and the e antigen receive no immunoprophylaxis, 70% to 90% become infected with the virus, and almost all become chronic carriers. Among infants in this study who received hepatitis B immune globulin at birth and three 5-micrograms doses of yeast-recombinant hepatitis B vaccine, only 4.8% became chronic carriers, a better than 90% level of protection and a rate that is comparable with that seen with immune globulin and plasma-derived hepatitis B vaccine. These data suggest that, in this high-risk setting, the yeast-recombinant vaccine is as effective as the plasma-derived vaccine in preventing hepatitis B virus infection and the chronic carrier state.

Predeposited autologous blood for elective surgery. A national multicenter study

To determine the extent to which autologous blood that has been donated in advance ("predeposited") is used in patients undergoing elective surgery and to assess whether predonation decreases the use of homologous blood and the demand on the blood supply, we studied 4996 patients undergoing elective surgery at 18 tertiary care hospitals. Cross-matched blood was ordered for 1287 patients (26 percent), and of these, 590 (46 percent) were considered eligible for predepositing blood. Only 5 percent (32) of the eligible patients actually predeposited blood, indicating that predonation is not widely used. Of those who predeposited, only 13 percent (4 of 32) subsequently received homologous blood, as compared with 36 percent (199 of 558) of those who did not predeposit (P less than 0.01). Among the 199 patients who did not predeposit but required transfusion, we estimate that predonation could have avoided homologous transfusion in as many as 68 percent. If all eligible patients had predeposited autologous blood, they could have supplied as much as 72 percent of their own transfused red cells. The blood for as much as 10 percent of all red-cell transfusions could have been predonated by and transfused into the patients undergoing elective surgery. Greater use of predonation would not only reduce the demand on the blood supply by decreasing the need for homologous transfusion, but would probably also reduce the risk of hepatitis and other transfusion-associated illnesses.

Underutilization of autologous blood donation among eligible elective surgical patients

In January 1983, blood banks encouraged the use of autologous blood for transfusion in elective surgical patients due to the advent of transfusion-associated AIDS. Since autologous blood does not transmit hepatitis and other viruses and does not cause alloimmunization, it should be utilized whenever possible. To determine whether patients eligible to predeposit autologous blood before elective operation were actually doing so, we studied patients at three hospitals between January 1 and June 30, 1985. Patients considered eligible for autologous predeposit blood donation were adults with preoperative hemoglobin levels of 11 g/dl or more who underwent elective surgical procedures for which blood transfusion was anticipated. Excluded were patients undergoing cardiovascular, intracranial, or renal transplant procedures. Of eligible patients, only 11 percent (32 of 278) predeposited blood; of these, 81 percent (26 of 32) were transfused with only autologous blood. Among eligible patients who did not predeposit blood, all could have benefited from predepositing because transfusion was likely for the procedure. Of those who did not predeposit, 33 percent (83 of 246) received homologous blood and therefore would have benefited from autologous donation. We conclude that autologous donations are underutilized for medically eligible patients undergoing elective operation.

Factors associated with positive direct antiglobulin tests in pretransfusion patients: a case-control study

During routine pretransfusion testing, the presence of IgG on patient red cells is suggested by a positive autocontrol and confirmed by a positive direct antiglobulin test (DAT) using monospecific anti-IgG sera. Most IgG on patient red cells detected in this manner are of unknown etiology. We recently showed an association between elevated serum globulin levels and positive DAT with unreactive eluate in patients with acquired immunodeficiency syndrome (AIDS). In the present study, we wished to determine whether elevated serum globulin levels contribute to some of the positive DAT encountered in pretransfusion testing of patients without AIDS. 76 patients with positive DAT were compared with 90 controls without IgG detected on their red cells during pretransfusion testing. The rate of elevated serum globulin levels was 75% in positive DAT cases versus 29% in controls (p less than 0.001); the odds ratio was 7.6. Elevated blood urea nitrogen levels occurred in 42% of cases versus 19% of controls (p less than 0.025); the odds ratio was 3.1. Cases and controls were not significantly different with regard to age, sex, race, quinidine usage, or hyperalimentation. Elevated serum globulin and blood urea nitrogen levels are significantly associated with a positive DAT with unreactive eluate in pretransfusion patients.

Positive direct antiglobulin test associated with hyperglobulinemia in acquired immunodeficiency syndrome (AIDS)

This study determined the prevalence and clinical significance of a positive direct antiglobulin test (DAT) observed in pretransfusion tests on red cells from patients with acquired immunodeficiency syndrome (AIDS). Transfusion service records showed that prevalence of a positive DAT on red cells was 18% (10/55) in AIDS patients compared to 0.6% in general hospital patients during a 2-year period (1981-1983). A similar rate of 18% (8/45) was observed in other hyperglobulinemic patients. Of the 10 AIDS patients whose red cells were DAT positive, four had IgG and complement, four had IgG, and two had complement alone on their red cells. The eluates were not reactive with normal red cells nor with penicillin or cephalothin-coated red cells. Clinically, no hemolysis was observed. In this series a positive DAT in AIDS patients appeared not to be associated with autoimmune hemolytic anemia. The positive DAT in AIDS patients may be due to the hyperglobulinemic state.

Agglutination of an EDTA blood sample caused by an EDTA-dependent panagglutinin

A novel example of an EDTA-dependent panagglutinin is described. A blood sample drawn into EDTA for a routine hematologic workup demonstrated strong agglutination due to EDTA-dependent panagglutinins. Previous examples have been detected because of discrepant ABO results. This is the first report of an EDTA-dependent panagglutinin that caused agglutination in the EDTA sample collection tube and a false positive direct antiglobulin test.

Effect of fibronectin on adherence of Staphylococcus aureus to fibrin thrombi in vitro

Staphylococcus aureus binds to purified fibronectin in solution and may bind to fibronectin present in wound tissue. When incorporated into a solid fibrin thrombus, however, plasma fibronectin may fail to bind S. aureus, because the S. aureus-binding sites on fibronectin may be occupied by fibrin. Both S. aureus and fibrin bind to the same 27-kilodalton amino-terminal fragment of fibronectin. To determine whether fibronectin incorporated into fibrin still promotes the adherence of S. aureus, we clotted citrated normal plasma and fibronectin-depleted plasma onto petri dishes. We then measured bacterial adherence to these in vitro fibrin thrombi. We found that the adherence of five of seven S. aureus strains decreased significantly (by 26 to 58%) when fibronectin had been depleted from the fibrin thrombi. Adding fibronectin back reversed this decrease in adherence. The reversal was dose dependent; the increase was in proportion to the amount of fibronectin added back to the plasma. Bacteria known not to bind to fibronectin (Escherichia coli and Staphylococcus epidermidis) adhered 100-fold less than S. aureus, and their adherence was unaffected by the absence of fibronectin in the fibrin thrombus. We conclude that fibronectin incorporated into solid fibrin thrombi does mediate the adherence of most S. aureus strains to fibrin thrombi. Fibronectin may be an important molecule that mediates the adherence of S. aureus to fibrin in wounds.

Perinatal hepatitis B virus transmission in the United States. Prevention by passive-active immunization

Among infants born to women in whom sera are positive for both the hepatitis B surface antigen and the e antigen, 85% to 90% are infected with hepatitis B virus and become chronic hepatitis B surface antigen carriers. In a study to assess the effectiveness of passive-active prophylaxis (hepatitis B immune globulin and hepatitis B vaccine) of such infants, we screened 18,842 pregnant Asian-American women: 8.7% were positive for hepatitis B surface antigen and 3.0% were also positive for hepatitis B e antigen. Thus far, 113 infants have received hepatitis B immune globulin (0.5 mL at birth) and hepatitis B vaccine (three 20-micrograms doses beginning at birth or at 1 month) and have been followed up for nine to 18 months. Among these infants, 16 have become chronic carriers, an incidence of only 14.2%. All of the uninfected infants have retained high levels of antibody to surface antigen, suggesting that they have had an active immune response to the vaccine and should have long-term protection against hepatitis B virus.

Use of preserved autologous red blood cells to absorb warm autoantibodies from the serum of patients receiving blood transfusion therapy

This paper describes two practical methods for the preservation of pretransfusion patient red blood cells for antigen typing and autoabsorption during a course of transfusion therapy. Blood samples from patients who had serum warm autoantibodies and a positive direct antiglobulin test were collected, the serum frozen, and the red cell aliquots separately preserved by PVP-methanol or formaldehyde fixation. After storage and recovery, the IgG antibodies were dissociated and the cells used for absorption of the warm autoantibodies. The preserved red cells removed the warm autoantibodies as effectively as fresh red blood cells from the same patient. Preservation of autologous red cells prior to the onset of transfusion therapy provides an extension of the autoabsorption procedure and a simple alternative to differential absorption.

Simplified method for recovery of autologous red blood cells from transfused patients

Separation of autologous and transfused red blood cells from recently transfused patients is necessary for the proper identification of any red blood cell alloantibody or autoantibody. We compared two methods of separation: the standard technic of microhematocrit centrifugation with phthalate ester solution, and a simplified method of microhematocrit centrifugation without the use of esters. Autologous red blood cells were concentrated in the top layer of the capillary tube by both methods. Separation efficacy was comparable, as determined by blood group antigen reactivity. Good separation was achieved only in samples drawn three or more days post transfusion. Microhematocrit centrifugation without the use of phthalate esters is a simple method for the recovery of autologous red blood cells from recently transfused patients that can be performed by any standard clinical laboratory.

Transient anti-Gya in an untransfused man. Serologic characteristics and cell survival study

Anti-Gya was identified in the serum of a 71-year-old untransfused man of German descent. The anti-Gya was reactive in the antiglobulin test phase and was of the IgG1 subclass. The patient's red cells typed as Gy(a-). A survival study using 10 ml of ABO compatible Gy(a+) 51Cr labelled red blood cells indicated normal survival up to six days. The anti-Gya diminished in reaction strength, and three months after the patient's initial hospitalization the antibody was no longer demonstrable by standard manual techniques. We conclude that intravascular hemolysis would have been unlikely if this patient were transfused with Gy(a+) cells. However, due to the possibility of a delayed hemolytic transfusion reaction, Gy(a+) cells would have been given only if Gy(a-) cells were not available and the patient's red blood cell deficit were life-threatening.

Occlusive impedance plethysmography. A noninvasive method of diagnosis of proximal deep vein thrombosis

The purpose of this study was to assess and confirm the accuracy of impedance plethysmography (IPG) by the occlusive cuff method, in detecting proximal (popliteal, femoral and iliac) deep vein thrombosis in patients with symptomatic limbs. In 27 patients 30 consecutive limbs were studied with concurrent venography and IPG. The IPG result was normal in 9 of 9 limbs which were normal on venography, and abnormal in 15 of 16 limbs which showed venographic evidence of proximal deep vein thrombosis (DVT). An abnormal IPG strongly suggests proximal DVT (predictive value 0.88). A normal IPG virtually rules out proximal DVT (predictive value 1.0).