Inventory management strategies that reduce the age of red blood cell components at the time of transfusion.

BACKGROUND: There has been interest concerning patient outcomes when older red blood cell (RBC) components are utilized. Inventory management is key to maintaining a stock of fresher RBCs for general transfusion needs. We have altered our practice for RBC management to reduce RBC age at the time of transfusion. STUDY DESIGN AND METHODS: Retrospective review of RBC age at time of transfusion at a tertiary care hospital with active trauma service was performed. The baseline nonirradiated RBC inventory was decreased from 12 to 15 days of stock to 7 to 10 days of stock, with request made to the blood supplier for fresher RBCs, specified at 75% of RBCs less than 14 days old. The age of RBCs at time of receipt and at time of transfusion was tracked on a monthly basis for the next 12 months. RESULTS: The mean age of RBCs at transfusion was decreased by 9 days on average for the year. Significant decreases in the mean age of RBCs at transfusion were seen in the second half of the year, with 4 of 6 months seeing a mean age of less than 20 days. There were no documented incidences of hospital blood shortages after the reduction in inventory; no surgery was canceled or delayed because of inventory. CONCLUSION: Inventory age depends on active management, combined with vendor cooperation to receive fresher components. Reducing the age of RBC components transfused is possible without experiencing blood component shortages. Longer periods of observation may allow for further adjustment of stocking levels on a seasonal basis.

Anti-Jka that are detected by solid-phase red blood cell adherence but missed by gel testing can cause hemolytic transfusion reactions.

BACKGROUND: Kidd blood group antibodies are notorious for transient detection and hemolytic transfusion reactions. This report compares the rate of detection of anti-Jka when using gel column agglutination versus solid-phase red blood cell adherence (SPRCA) testing and documents the occurrence of hemolytic transfusion reactions in 17 recently transfused patients who developed anti-Jka that were detectable by SPRCA but were undetectable by gel. STUDY DESIGN AND METHODS: Before April 20, 2011, the laboratory used gel column agglutination as the primary method for antibody screening and identification. From April 20, 2011, to August 12, 2013, SPRCA was adopted as the primary method for antibody screen with gel remaining the primary method for identification. SPRCA identification was also performed if sufficient sample was available. Medical records were reviewed for evidence of hemolytic reaction in patients whose anti-Jka was negative or inconclusive by gel, but clearly identifiable by SPRCA at the time the anti-Jka was first identified. RESULTS: A total of 105 patients were discovered with anti-Jka from 88,478 SPRCA screens performed. In 32 patients, anti-Jka was initially discovered by SPRCA testing and concurrent gel testing was completely negative (n = 26) or inconclusive (n = 6). Seventeen of the 32 patients were recently transfused and of these six met criteria for delayed hemolytic transfusion reaction (DHTR), three had possible DHTRs, and eight had delayed serologic reactions; 13 of the transfused patients received Jk(a-) RBCs to avoid potential hemolysis. CONCLUSION: SPRCA testing significantly increased the discovery of clinically significant anti-Jka and facilitated the earlier use of Jk(a-) RBCs to avoid hemolytic transfusion reactions.

Microbial keratitis in los angeles: the doheny eye institute and the los angeles county hospital experience.

OBJECTIVE: To evaluate the spectrum and antibiotic susceptibility panel of infectious keratitis at a major tertiary care referral eye center and a major county hospital in Southern California. DESIGN: Retrospective case series. PARTICIPANTS: All cultured infectious keratitis cases from July 1, 2008, through December 31, 2012, from the Doheny Eye Institute (DEI) and the Los Angeles County + University of Southern California Medical Center (LAC+USC) were evaluated. METHODS: Microbiology records were reviewed retrospectively. MAIN OUTCOME MEASURES: Microbial isolates as well as antibiotic susceptibility patterns were analyzed. RESULTS: One hundred eighty-four (63%) of 290 cases showed positive culture results at DEI and 152 (82%) of 186 cases showed positive culture results at LAC+USC. Gram-positive pathogens were found to be the most common at both DEI (70%) and LAC+USC (68%), with coagulase-negative Staphylococcus being the most common gram-positive organism (58% at DEI and 44% at LAC+USC). Pseudomonas aeruginosa was the most common gram-negative organism (57% at DEI and 43% at LAC+USC). Ciprofloxacin and levofloxacin susceptibility for all tested pathogens was 73% at DEI and 81% at LAC+USC (P = 0.16). Oxacillin-resistant Staphylococcus aureus (ORSA) was found in 42% of cases at DEI and in 45% of cases at LAC+USC (P = 1.00). CONCLUSIONS: There is no significant difference in the spectrum of pathogens or antibiotic susceptibility of pathogens at DEI versus LAC+USC, and ORSA was found in approximately half of all S. aureus samples.

Life-threatening delayed hyperhemolytic transfusion reaction in a patient with sickle cell disease: effective treatment with eculizumab followed by rituximab.

BACKGROUND: Hyperhemolysis in sickle cell disease is a rare and potentially life-threatening complication of transfusion. STUDY DESIGN AND METHODS: In this article we report a case of delayed hemolytic transfusion reaction with resultant hyperhemolysis triggered by an anti-IH autoantibody with alloantibody behavior. RESULTS: The anti-IH was reactive at room temperature as well as 37 °C, but only weakly reactive with autologous red blood cells. Initial cold agglutinin titer was 512. The profound, life-threatening, intravascular hemolysis was rapidly and dramatically reduced with the Complement 5 (C5) inhibitory antibody, eculizumab. The auto/allo cold agglutinin was subsequently suppressed with rituximab treatment. CONCLUSIONS: Eculizumab, a potent C5 inhibitory antibody, can be a rapid and effective therapy for hyperhemolytic transfusion reactions when given in a sufficient dose to fully block the activation of complement C5.

Making thawed universal donor plasma available rapidly for massively bleeding trauma patients: experience from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial.

BACKGROUND: The Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial was a randomized clinical trial comparing survival after transfusion of two different blood component ratios for emergency resuscitation of traumatic massive hemorrhage. Transfusion services supporting the study were expected to provide thawed plasma, platelets, and red blood cells within 10 minutes of request. STUDY DESIGN AND METHODS: At the 12 Level 1 trauma centers participating in PROPPR, blood components transfused and delivery times were tabulated, with a focus on universal donor (UD) plasma management. The adequacy of site plans was assessed by comparing the bedside blood availability times to study goals and the new American College of Surgeons guidelines. RESULTS: Eleven of 12 sites were able to consistently deliver 6 units of thawed UD plasma to their trauma-receiving unit within 10 minutes and 12 units in 20 minutes. Three sites used blood group A plasma instead of AB for massive transfusion without complications. Approximately 4700 units of plasma were given to the 680 patients enrolled in the trial. No site experienced shortages of AB plasma that limited enrollment. Two of 12 sites reported wastage of thawed AB plasma approaching 25% of AB plasma prepared. CONCLUSION: Delivering UD plasma to massively hemorrhaging patients was accomplished consistently and rapidly and without excessive wastage in high-volume trauma centers. The American College of Surgeons Trauma Quality Improvement Program guidelines for massive transfusion protocol UD plasma availability are practicable in large academic trauma centers. Use of group A plasma in trauma resuscitation needs further study.

Verification and Implementation of HIV Antibody Differentiation Testing to Improve Turnaround Time for the HIV Diagnostic Algorithm.

BACKGROUND: Relying on reference laboratories for HIV confirmation testing may lead to delays in treatment and can cause stress for patients who have positive HIV screening results. OBJECTIVE: To internalize HIV-1/HIV-2 antibody differentiation testing within the hospital laboratory. METHODS: We analytically verified an HIV antibody differentiation immunoassay and subsequently compared result turnaround times (TATs) for HIV antibody differentiation and HIV-1 qualitative RNA in the months before and after the test internalization. RESULTS: HIV antibody differentiation was successfully verified. TATs for HIV antibody differentiation and HIV-1 RNA significantly improved, from medians of 40.4 hours and 156.5 hours to medians of 17.7 hours and 56.5 hours, respectively, after the internalization. The 90th-percentile turnaround times declined by 72% and 44%, respectively. CONCLUSIONS: It is feasible for a hospital laboratory to verify HIV antibody-differentiation testing. Its implementation may considerably improve result TATs for the HIV diagnostic algorithm.

Diagnostic reproducibility of cervical intraepithelial neoplasia 3 and atrophy in menopausal women on hematoxylin and eosin, Ki-67, and p16 stained slides.

OBJECTIVE: To establish diagnostic accuracy and reproducibility of a diagnosis of cervical intraepithelial neoplasia 3 (CIN 3) in menopausal women on routinely stained hematoxylin and eosin (H&E) slides and compare it to slides processed for p16 and Ki-67. MATERIALS AND METHODS: Confirmed cases of CIN 3 and benign atrophic changes were reviewed independently by 4 pathologists. The samples were studied on separate occasions using H&E staining, p16, and Ki-67. Differences in sensitivity and specificity between reviewers or methods were tested for significance using the McNemar test, whereas differences in positive and negative predictive values were tested for significance using a marginal probability generalized linear model for agreement. RESULTS: Sensitivity was high for H&E (93.3%-100%) and Ki-67 (93.3%-100%) and lower for p16 (70.0%-90.0%). Intraobserver variability was also lower for p16 (76.7% vs 90.0%, although this difference was not statistically significant, p = .219). p16 agreement, however, for CIN 3 is significantly lower than that for atrophy (76.7% vs 97.4%, p = .018). CONCLUSIONS: Routine histopathologic diagnosis of CIN 3 in menopausal women is highly accurate and reproducible. Both H&E and Ki-67 are useful immunohistochemical stains in helping differentiate atrophy from high-grade cervical intraepithelial lesions in postmenopausal cervical biopsies. There may be more disagreement among readers using p16.

Group A emergency-release plasma in trauma patients requiring massive transfusion.

BACKGROUND: Both groups A and AB plasma have been approved for emergency-release transfusion in acutely bleeding trauma patients before blood grouping being performed. The safety profile associated with this practice has not been well characterized, particularly in patients requiring massive transfusion. METHODS: This secondary analysis of the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios trial examined whether exposure to group A emergency-release plasma (ERP) was noninferior to group AB ERP. We also examined patients whose blood groups were compatible with group A ERP versus patients whose blood groups were incompatible with group A ERP. Outcomes included 30-day mortality and complication rates including systemic inflammatory response syndrome, infection, renal injury, pulmonary dysfunction, and thromboembolism. RESULTS: Of the 680 patients predicted to receive a massive transfusion, 584 (85.9%) received at least 1 U of ERP. Of the 584 patients analyzed, 462 (79.1%) received group AB and 122 (20.9%) received group A ERP. Using a hazard ratio (HR) of 1.35 as the noninferiority margin, transfusion with group A versus group AB ERP was not associated with increased thromboembolic rates (HR, 0.52; 95% confidence interval [CI], 0.31-0.90). Mortality (HR, 1.15; 95% CI, 0.91-1.45) and nonfatal complication rates (HR, 1.24; 95% CI, 0.87-1.77) were inconclusive. In the subgroup analysis, transfusion with incompatible ERP (group B or AB patients receiving group A ERP) was not associated with increased nonfatal complications (HR, 1.02; 95% CI, 0.80-1.30). There were no reported hemolytic transfusion reactions. CONCLUSION: The use of ERP is common in patients requiring massive transfusion and facilitates the rapid balanced resuscitation of patients who have sustained blood loss. Group A ERP is an acceptable option for patients requiring massive transfusion, especially if group AB ERP is not readily available. LEVEL OF EVIDENCE: Therapeutic/Care Management, level IV; Prognostic, level III.

Decreased mortality in patients with isolated severe blunt traumatic brain injury receiving higher plasma to packed red blood cells transfusion ratios.

INTRODUCTION: Higher transfusion ratios of plasma to packed red blood cells (PRBC) and platelets (PLT) to PRBC have been shown to be associated with decreased mortality in major trauma patients. However, little is known about the effect of transfusion ratios on mortality in patients with isolated severe traumatic brain injury (TBI). The aim of this study was to investigate the effect of transfusion ratios on mortality in patients with isolated severe blunt TBI. We hypothesized that higher transfusion ratios of plasma to PRBC and PLT to PRBC are associated with a lower mortality rate in these patients. METHODS: Retrospective observational study. Patients with isolated severe blunt TBI (AIS head≥3, AIS extracranial <3) admitted to an urban level I trauma centre were included. Clinical data were extracted from the institution's trauma registry, blood transfusion data from the blood bank database. The effect of higher transfusion ratios on in-hospital mortality was analysed using univariate and multivariable regression analysis. RESULTS: A total of 385 patients were included. Median age was 32 years (IQR 2-50), 71.4% were male, and 76.6% had an ISS≥16. Plasma:PRBC transfusion ratios≥1 were identified as an independent predictor for decreased in-hospital mortality (adjusted OR 0.43 [CI 0.22-0.81]). PLT:PRBC transfusion ratios≥1 were not significantly associated with mortality (adjusted OR 0.39 [CI 0.08-1.92]). CONCLUSION: This study revealed plasma to PRBC transfusion ratios≥1 as an independent predictor for decreased in-hospital mortality in patients with isolated severe blunt TBI.

Origin, Presentation, and Clinical Course of Nonpancreatic Hyperlipasemia.

OBJECTIVE: The diagnosis of acute pancreatitis (AP) is defined as a constellation of abnormal pancreatic enzymes, imaging, and characteristic pain. The origin and clinical significance of isolated hyperlipasemia is unclear. METHODS: We prospectively evaluated patients with serum lipase level greater than 3 times the upper limit of normal (ULN) admitted to Los Angeles County Hospital from October 2014 to April 2015. Patients were identified by a daily laboratory query used to support an ongoing randomized trial of goal-directed therapy for AP (NCT 01761539). Nonpancreatic hyperlipasemia (NPHL) was defined as a serum lipase level greater than 3 times the ULN without characteristic pain or imaging. RESULTS: Among 221 patients with lipase level greater than 3 times the ULN, 170 met criterion for AP, and 51 did not. The leading etiologies for NPHL were decompensated cirrhosis and renal failure. Patients with NPHL were significantly older and had more comorbidities and lower serum lipase levels (360 ± 36 vs 1453 ± 135 IU/L, P < 0.001). There were no differences in length of hospitalization, intensive care unit admission, or mortality. CONCLUSIONS: Elevated serum lipase level has many nonpancreatic origins, with liver and renal failure being the most frequent. Distinct clinical features can help to differentiate between AP and NPHL.

Non-specific red cell reactivity in an obstetric population.

OBJECTIVE: To examine non-specific red cell reactivity (NSR) on antibody (Ab) screening of obstetric inpatients. METHODS: Observational study of 5438 obstetric inpatients (2009-2013). Ab-positive patients were identified and their records reviewed for NSR, other antibodies, transfusion reactions or hemolytic disease of the fetus/newborn (HDFN). Evaluation of NSR frequency by test era assessed the impact of an institutional change to solid-phase screening in 2011. RESULTS: Of obstetric inpatients, 5.3% had at least one positive Ab screen; 1.6% had NSR. Of NSR-positive patients, 16.7% had identifiable Abs that pre-dated NSR; 25% had concurrent Abs and 8.5% had subsequent Ab identification. In 49.1%, NSR resolved during follow-up. The frequency of NSR was higher after the change to solid-phase Ab screening, but specific Ab frequency was similar in both testing periods. No transfusion reactions or cases of HDFN were noted in this cohort. CONCLUSIONS: NSR is found in 1-2% of obstetrical inpatients at our institution, and has more than doubled since the initiation of solid-phase screening. Although likely clinically insignificant by itself, NSR is commonly found in relation to other red cell Abs and may precede their development.

Critical laboratory value notification: a failure mode effects and criticality analysis.

BACKGROUND: The Failure Mode Effects and Criticality Analysis (FMECA) was applied to improve the timeliness of reporting and the timeliness of receipt by the responsible licensed caregiver of critical laboratory values (CLVs) for outpatients and non-critical care inpatients. METHODS: Through a risk prioritization process, the most important areas for improvement, including contacting the provider, assisting the provider in contacting the patient, and educating the provider in follow-up options available during off hours, were identified. ACTIONS TAKEN: A variety of systemic improvements were made; for example, the CLV notification process was centralized in the customer service center, with databases to help providers select options and make arrangements for follow-up care and an electronic abstract form to document the CLV notification process. Review of documentation and appropriateness of CLV follow-up care was integrated into the quality monitoring process to detect any variations or problems. RESULTS: The average CLV notification time for the month steadily declined during an eight-month period. Compliance was 100% for the "read-back" requirement and documentation in patient's health record. DISCUSSION: This proactive risk assessment project successfully modified the CLV notification program from a high- to a low-risk process, identified activities to further improve the process, and helped ensure compliance with a variety of requirements.

Fetal-Maternal Hemorrhage Detected by Sudden Disappearance of Rh Immune Globulin-Related Anti-D.

BACKGROUND: Fetal-maternal hemorrhage is usually spontaneous and goes undetected but can be associated with adverse perinatal outcomes. CASE: We describe the detection of a fetal-maternal hemorrhage by abrupt disappearance of prophylactic anti-D on antibody screen in an Rh-negative mother with dichorionic twins admitted for atrial flutter of one twin. Both rosette and Kleihauer-Betke tests were positive. The diagnosis was confirmed by anemia in one twin at birth. CONCLUSION: Fetal-maternal hemorrhage requires a high index of suspicion for diagnosis. An unexpected sudden decline in Rh immune globulin-related anti-D may be an indication of fetal-maternal hemorrhage.

Candida Score as a Predictor of Worse Outcomes and Mortality in Severely Injured Trauma Patients with Positive Candida Cultures.

Invasive candidiasis is associated with worse outcomes and increased mortality in critically ill patients. The Candida score (CS) provides a clinical tool for identifying patients at risk for invasive candidiasis. Outcomes of severely injured trauma patients with positive candida cultures stratified by their CS have not been well described. In this retrospective observational study, all severely injured trauma patients (Injury Severity Score ≥16) admitted to the Los Angeles County and University of Southern California Medical Center from April 2008 to April 2014 with positive Candida cultures were included. Outcomes of patients with a low risk for invasive candidiasis (CS < 3) were compared with those with a high risk (CS ≥ 3). A CS ≥ 3 was significantly associated with higher mortality (35.9% vs 5.0%, P = 0.001), longer length of stay (LOS) (median 49.0 vs 28.0, P = 0.002), longer intensive care unit LOS (35.0 vs 20.0, P < 0.001), requirement for renal replacement therapy (38.5% vs 4.9%, P < 0.001), and increased ventilator days (22.0 vs 12.0, P < 0.001). Multivariable regression analysis revealed a CS ≥ 3 as a significant predictor for increased mortality [OR 6.983], longer LOS [regression coefficient (RC) 1.572] and intensive care unit LOS (RC 1.698), more frequent need for renal replacement therapy (OR 13.268), and increased ventilator days (RC 1.836). In conclusion, a CS ≥ 3 is significantly associated with increased mortality and worse outcomes in severely injured trauma patients with positive Candida cultures. The CS thus may serve as a clinical tool to predict outcomes in this patient population.

Patient safety and blood transfusion: new solutions.

Current risk from transfusion is largely because of noninfectious hazards and defects in the overall process of delivering safe transfusion therapy. Safe transfusion therapy depends on a complex process that requires integration and coordination among multiple hospital services including laboratory medicine, nursing, anesthesia, surgery, clerical support, and transportation. The multidisciplinary hospital transfusion committee has been traditionally charged with oversight of transfusion safety. However, in recent years, this committee may have been neglected in many institutions. Resurgence in hospital oversight of patient safety and transfusion efficacy is an important strategy for change. A new position, the transfusion safety officer (TSO), has been developed in some nations to specifically identify, resolve, and monitor organizational weakness leading to unsafe transfusion practice. New technology is becoming increasingly available to improve the performance of sample labeling and the bedside clerical check. Several technology solutions are in various stages of development and include wireless handheld portable digital assistants, advanced bar coding, radiofrequency identification, and imbedded chip technology. Technology-based solutions for transfusion safety will depend on the larger issue of the technology for patient identification. Devices for transfusion safety hold exciting promise but need to undergo clinical trials to show effectiveness and ease of use. Technology solutions will likely require integration with delivery of pharmaceuticals to be financially acceptable to hospitals.

Use of plasma in the management of central nervous system bleeding: evidence-based consensus recommendations.

INTRODUCTION: Central nervous system (CNS) hemorrhage is a potentially life-threatening condition, especially in patients with acquired coagulopathy. In this setting, treatment of CNS bleeding includes hemostatic therapy to replenish coagulation factors. There is currently a debate over the hemostatic efficacy of plasma in many clinical settings, alongside increasing concern about transfusion-associated adverse events. Despite these concerns, plasma is widely used. Moreover, plasma transfusion practice is variable and there is currently no uniform approach to treatment of traumatic, surgical or spontaneous CNS hemorrhage. This study addresses the need for guidance on the indications and potential risks of plasma transfusion in these settings. An Expert Consensus Panel was convened to develop recommendations guiding the use of plasma to treat bleeding and/or coagulopathy associated with CNS hemorrhage. The panel did not advise on the best treatment available but rather proposed recommendations to be used in the formulation of local procedures to support emergency physicians in their decision-making process. METHODS: Evidence was systematically gathered from the literature and rated using methods established by the Scottish Intercollegiate Guidelines Network. The evidence was used to develop graded consensus recommendations, which are presented along with the evidence-based rationale for each in this report. RESULTS: Sixty-five articles were identified covering both vitamin K antagonist-anticoagulation reversal and treatment of bleeding/coagulopathy in non-anticoagulated patients. Recommendations were then developed in four clinical scenarios within each area, and agreed on unanimously by all members of the panel. CONCLUSION: The Panel considered plasma to be reasonable therapy for CNS hemorrhage requiring urgent correction of coagulopathy, although physicians should be prepared for potential cardiopulmonary complications, and evidence suggests that alternative therapies have superior risk-benefit profiles. Plasma could not be recommended in the absence of hemorrhage or coagulopathy. Consideration of the absolute risks and benefits of plasma therapy before transfusion is imperative.

Pretransfusion testing practices in North America, 2005-2010: an analysis of the College Of American Pathologists Interlaboratory Comparison Program J-survey data, 2005-2010.

CONTEXT: Data collection and analysis of the College of American Pathologists (CAP) Interlaboratory Comparison Program (Proficiency Testing) J-Survey results provide insights into North American pretransfusion compatibility testing practices and trends. OBJECTIVES: To assess current North American manual testing practices for ABO grouping, rhesus (Rh) typing, antibody screening, and crossmatching using CAP proficiency testing data. DESIGN: Analysis of the CAP Interlaboratory Comparison Program J-Survey data (2005-2010) to identify laboratory methods used for ABO grouping, Rh typing, antibody screening, and crossmatching. Data were analyzed by test method using Microsoft (Redmond, Washington) Excel software. RESULTS: The method used most often in ABO grouping and Rh typing was tube testing. Many laboratories also used tube testing for antibody detection and crossmatching, but during the study period, the proportion of laboratories using gel-based methodologies increased considerably. CONCLUSIONS: Most North American CAP laboratories continue to use tube methods for ABO/Rh testing. Use of gel-based methodologies increased during the past 5 years for antibody screening and crossmatching.

Transfusion of platelets containing ABO-incompatible plasma: a survey of 3156 North American laboratories.

CONTEXT: Hemolytic transfusion reactions due to platelet transfusions containing ABO-incompatible plasma (ie, group O platelets into a non-group O patient) have been reported in the literature. However, limited data describe the extent to which transfusion services manage such platelet transfusions or the methods used to limit the risk of such reactions. OBJECTIVE: To determine transfusion services' current practices regarding the use of platelets containing ABO-incompatible plasma. DESIGN: In a College of American Pathologists' Transfusion Medicine Proficiency Testing Survey, supplemental questions asked participants whether a policy existed for the use of platelets containing ABO-incompatible plasma and, if a policy existed, what elements were part of the policy. RESULTS: Of 3156 laboratories that transfused platelets, 3152 responded to the question of whether they had a policy. Of these respondents, 83% (n = 2623) had a policy. One or more elements were reported for transfusions in adults: only ABO-compatible plasma products (n = 1363); only ABO-compatible plasma and platelet products (n = 679); notification of medical director (n = 646); notification of ordering physician (n = 637); volume limit of ABO-incompatible plasma allowed (n = 255); volume-reduction of ABO-incompatible products (n = 168); screening for critical titer of anti-A or anti-B (n = 53). A total of 529 laboratories indicated that they did not have a policy. CONCLUSIONS: A majority of laboratories have a policy, but most do not include a method to limit the risk of hemolysis if platelets containing ABO-incompatible plasma must be transfused. When such platelets are used, there does not appear to be consensus on a specific method to minimize the transfusion of anti-A or anti-B.