A transfusion prescription template and other human factor interventions to improve balanced transfusion delivery in major haemorrhage due to trauma.

OBJECTIVES: The aim of this study is to improve practice in the management of major haemorrhage, particularly in red cell to plasma transfusion ratios. BACKGROUND: A review of the management of major haemorrhage in trauma in Newcastle Hospitals Trust in 2012-2013 showed good mortality outcomes but found that red cell : plasma transfusion ratios could be improved. Human factors techniques transferable from industry and the military were identified, and a package of interventions was implemented, including an intensive multidisciplinary team training programme and a new major haemorrhage prescription template. METHODS/MATERIALS: We reviewed the management of all 243 adult trauma patients admitted with major haemorrhage to the Emergency Department in the Newcastle Hospitals Trust in the 4-year period from April 2012. We analysed clinical details, blood components transfused and patient outcomes and used Trauma Audit and Research Network data to correlate with injury severity and predicted survival. RESULTS: Mean transfusion ratios of red cells to plasma improved from 1·5 : 1 and 1·6 : 1 in the first 2 years to 1·1 : 1 in the 2 years following implementation of the new measures. There was a statistically significant improvement in the delivery of a balanced transfusion, defined as a red cell : plasma ratio of <1·3 : 1 following the changes. CONCLUSION: Simple changes to procedures, specifically implementation of a new major haemorrhage prescription template and multidisciplinary team training, have resulted in marked improvement in the ratio of red cells to plasma transfused to trauma patients with major haemorrhage or requiring emergency blood. The package of changes could be easily replicated in other health-care settings.

Cardiopulmonary exercise testing before and after blood transfusion: a prospective clinical study.

BACKGROUND: Cardiopulmonary exercise testing (CPET) is used to risk-stratify patients undergoing major elective surgery, with a poor exercise capacity being associated with an increased risk of complications and death. Patients with anaemia have a decreased exercise capacity and an increased risk of morbidity and mortality after major surgery. Blood transfusion is often used to correct anaemia in the perioperative period but the effect of this intervention on exercise capacity is not well described. We sought to measure the effect of blood transfusion on exercise capacity measured objectively with CPET. METHODS: Patients with stable haematological conditions requiring blood transfusion underwent CPET before and 2-6 days after transfusion. RESULTS: Twenty patients were enrolled and completed both pre- and post-transfusion tests. The mean (sd) haemoglobin (Hb) concentration increased from 8.3 (1.2) to 11.2 (1.4) g dl(-1) after transfusion of a median (range) of 3 (1-4) units of packed red cells. The anaerobic threshold increased from a mean (sd) of 10.4 (2.4) to 11.6 (2.5) ml kg(-1) min(-1) (P=0.018), a mean difference of 1.2 ml kg(-1) min(-1) (95% confidence interval (CI)=0.2-2.2). When corrected for the change in Hb concentration, the anaerobic threshold increased by a mean (sd) of 0.39 (0.74) ml kg(-1) min(-1) per g dl(-1) Hb. CONCLUSIONS: Transfusion of allogeneic packed red cells in anaemic adults led to a significant increase in their capacity to exercise. This increase was seen in the anaerobic threshold, and other CPET variables.

Strategies to reduce transfusion acquired vCJD.

Variant Creutzfeldt-Jakob disease (vCJD) can be transmitted by transfusion. The risk depends on the number of infected donors in the community. An estimate of these numbers in a less genetically susceptible population, based on the epidemic seen so far, suggests a maximum of 300 more cases. From this, it is possible to predict a maximum of one transfusion acquired case in 3 years from plasma transfusion. Importation of plasma from outside the UK has been advocated to prevent these cases and would cost around £30 million per year. An alternative measure is to use the observed susceptibility and exposure to dietary vCJD by age, and to target low risk donors for the production of components such as fresh frozen plasma (FFP) and platelets. This will reduce the possible cases of plasma transfusion-acquired vCJD at little or no extra cost to the health service.

How much residual plasma may cause TRALI?

Although passive infusion of plasma-rich components containing white blood cell (WBC) antibodies are responsible for majority of the reported transfusion-related acute lung injury (TRALI) cases, the minimum volume of residual plasma, which might trigger TRALI, is not known. We report three cases of TRALI where the implicated donor component contained between 10 and 20 mL of residual plasma. Two cases were related to transfusion of red blood cells prepared in optimal additive solution, and the other was related to transfusion of pooled buffy coat platelets. In the latter case, WBC antibodies that matched the patient's human leucocyte antigen (HLA) antigens were only found in one buffy coat donor (female) who contributed a buffy coat for pooled platelets preparation. Plasma prepared from pooling platelets was collected from a male donor. Laboratory investigation confirmed that in all three cases, the donors' serum contained three to four different HLA class 1-specific and class 11-specific antibodies that matched with the patient's HLA type. Our cases suggest that the residual plasma volume as small as 10-20 mL containing donor derived WBC antibodies may cause TRALI. The risk of TRALI remains, despite providing pooled platelets suspended in male donor plasma. The significance of multiple HLA antigen/antibody matching between donor and recipient in immune TRALI warrants further study.

Changing indications for red cell transfusion from 2000 to 2004 in the North of England.

Falling donor numbers and the threat of transfusion-transmitted variant Creutzfeldt-Jakob disease may lead to shortages in the national blood supply. Knowledge of current patterns of transfusion and trends in usage will help predict future change in blood use. Our previous survey identified medical indications as the major reason for transfusion, but detailed information within this category was limited. We performed prospective surveys of indications for red cell transfusion for two 14-day periods in 2004 in the North of England, concentrating on medical reasons for transfusion. Data were obtained for transfusion indications of 9003 units, which accounted for over 99% of red cell issues from the regional blood centre during the study. In 2004, medical patients received 62% (5558 units) of all transfused units, surgical patients 33% (3001 units) and Obstetric & Gynaecology patients 5% (444 units). These figures compare with 52, 41 and 6% for Medicine, Surgery, and Obstetrics & Gynaecology in 1999/2000. The three largest uses of blood within the medical category were for patients with primary haematological disorders (18.2% of all transfused blood), for management of gastrointestinal haemorrhage (13.8%) and for patients with nonhaematological malignancies (8.8%). There has been a significant reduction in use of blood for surgical indications over the last 5 years, but an absolute increase in use of blood for medical indications. Lower transfusion triggers, education, use of cell salvage, the increasing price of a unit of red cells and changing population demographics may all have contributed to the reduction in surgical blood use. Promotion of good transfusion practice and alternatives to allogeneic transfusion should now focus on medical and surgical use of blood transfusion.

Recovery from post-operative anaemia.

Acceptance of lower transfusion thresholds and shorter post-operative stays results in patients leaving hospital after surgery with lower haemoglobin (Hb) than previously. We undertook a prospective observational study to assess the haematological response to post-operative anaemia and to determine the utility of quality of life (QoL) measures in assessing the impact of anaemia on such patients. Thirty patients undergoing unilateral hip arthroplasty had blood samples taken and QoL questionnaires administered pre-operatively and at 7, 28 and 56 days post-operatively. Increased erythropoiesis was evident at day 7 post-operatively. Approximately two-thirds of the post-operative Hb deficit was corrected by day 28. There was evidence of functional iron deficiency in more than one-quarter of patients at day 56. QoL scores used did not show any relationship with Hb in the post-operative period. Red cell 2,3-diphosphoglycerate (2,3DPG) levels increased in proportion to the degree of post-operative anaemia. We concluded that substantial recovery of Hb occurs between day 7 and day 28 post-operatively. Complete recovery of Hb may be delayed beyond day 56 due to development of iron deficiency. Patients are at significant risk of developing post-operative iron deficiency depending on operative blood loss and pre-operative iron stores. Increased red cell 2,3DPG may offset the effect of anaemia on oxygen delivery. We found no evidence that anaemia produces a measurable effect on chosen QoL scores in the post-operative period.

Nitric oxide and blood: a review.

Nitric oxide (NO) was identified as a physiological mediator of vascular tone in 1987. NO produced by endothelial cells causes vasodilatation and also inhibits platelet aggregation and leucocyte adhesion. Red cells metabolize NO to nitrate but may possibly carry and release, or even produce, NO in hypoxic conditions. NO physiology may have important implications for transfusion medicine, ranging from adverse effects of haemoglobin substitutes to preservation of stored platelets and to detrimental effects of stored red cells.

Transfusion-related acute lung injury caused by two donors with anti-human leucocyte antigen class II antibodies: a look-back investigation.

Transfusion-related acute lung injury (TRALI) is considered as one of the most important complications of blood transfusion. Previous look-back investigations have revealed unrecognized cases. We report two cases of TRALI in brief and the outcomes of transfusion in the recipients of previous components from the implicated donors. This look-back investigation was a retrospective case-note study assessing whether there were any untoward events associated with the previous transfusions. 18 patients were identified as having received a blood component transfusion from one of the two donors with anti-human leucocyte antigen (HLA) antibodies to antigens occurring frequently in the local population. One of the five patients receiving a unit of fresh frozen plasma had an evidence of TRALI, which was not diagnosed at the time. A second patient, who had been HLA typed and who carried a full match of antigens for the antibody specificities of the plasma received, had no evidence of a reaction. There were no documented reactions in 13 recipients of red cells in optimal additive (OA) solution. Cases of TRALI may go unrecognized. Not all patients with antibody/antigen concordance will develop clinical signs. Red cells in OA solution from donors with anti-HLA antibodies appear to have a low risk of causing clinically evident lung damage.

'Tag and label' system for checking and recording of blood transfusions.

Guidelines for checking and recording of blood transfusion mandate the use of a blood transfusion compatibility form. We have introduced and assessed a 'tag and label' system that does away with the compatibility form. A compatibility tag with a peel-off self-adhesive label is attached to the unit for transfusion. No compatibility form is issued to the site of the transfusion. The peel-off label is signed and fixed in patient notes at the time of transfusion. We have found the system easier to use and to be preferred by nursing staff administering transfusions. During 2 years, we have transfused over 100,000 blood components, including 70,000 units of red cells, and have not recognized any episode during which the wrong blood was transfused to a patient. Recording in the patient notes of units transfused has significantly improved compared with local and national figures in a previous survey. We conclude that it is possible to dispense with the compatibility form without compromising the safety of the transfusion process.

Management of transfusion-related acute lung injury with extracorporeal cardiopulmonary support in a four-year-old child.

We report a case of successful management of transfusion-related acute lung injury (TRALI) with prolonged cardiopulmonary bypass support in a 4-yr-old patient undergoing elective cardiac surgery. TRALI was diagnosed clinically and immunologically by detection of reactive antibodies in a unit of fresh frozen plasma that had been administered to the patient. The aetiology and management of TRALI are briefly discussed and possible implications of this case for the management of TRALI are highlighted.

Effect of WBC reduction of transfused RBCs on postoperative infection rates in cardiac surgery.

BACKGROUND: WBC-replete blood transfusion has been suggested as an independent cause of increased postoperative infection. STUDY DESIGN AND METHODS: A total of 597 patients undergoing elective coronary artery or heart valve surgery were randomly assigned to receive plasma-reduced (PR), buffy coat-depleted (BCD), or WBC-filtered (WCF) RBCs in the event of requiring blood transfusion. Details of postoperative course were recorded. Further information was collected from the patient's general practitioner 3 months after discharge. RESULTS: No significant difference in inpatient infection rates was observed among patients randomly assigned to receive PR, BCD, or WCF RBCs. When only those receiving transfusion were analyzed (n = 509), use of PR RBCs was associated with more events coded as infections (p < or = 0.05) compared with BCD or WCF RBCs. However, when events coded as urinary tract infections were excluded, there was no significant difference among the three groups. Follow-up performed after discharge showed no difference in readmission rates, but a higher reported rate of infection in those randomly assigned to receive WCF RBCs (p < 0.02). CONCLUSION: No evidence has been found, analyzed by intention to treat, that use of WBC-reduced, BCD, or WCF RBCs reduces postoperative inpatient infection in patients undergoing cardiac bypass surgery.

Where does blood go? Prospective observational study of red cell transfusion in north England.

OBJECTIVE: To collect population based information on transfusion of red blood cells. DESIGN: Prospective observational study over 28 days. SETTING: Hospital blood banks in the north of England (population 2.9 million). MAIN OUTCOME MEASURES: Indications for transfusion, number of units given, and the age and sex of transfusion recipients. PARTICIPANTS: All patients who received a red cell transfusion during the study period. Data completed by hospital blood bank staff. RESULTS: The destination of 9848 units was recorded (97% of expected blood use). In total 9774 units were transfused: 5047 (51.6%) units were given to medical patients, 3982 (40.7%) to surgical patients, and 612 (6.3%) to obstetric and gynaecology patients. Nearly half (49.3%) of all blood is given to female recipients, and the mean age of recipients of individual units was 62.7 years. The most common surgical indications for transfusion were total hip replacement (4.6% of all blood transfused) and coronary artery bypass grafting (4.1%). Haematological disorders accounted for 15.5% of use. Overall use was 4274 units per 100 000 population per year. CONCLUSION: In the north east of England more than half of red cell units are transfused for medical indications. Demand for red cell transfusion increases with age. With anticipated changes in the age structure of the population the demand for blood will increase by 4.9% by 2008.