How do I reduce variation in red blood cell transfusion practices in a large integrated health care system?

BACKGROUND: Reducing variation in transfusion practices can prevent unwarranted transfusions, an outcome that improves quality of care and patient safety, while lowering costs and eliminating waste of blood. We developed and assessed a system-wide initiative to reduce variation in red blood cell (RBC) transfusion in terms of both transfusion utilization and the number of units transfused. INTERVENTION DESIGN AND METHODS: Our initiative combined a single-unit default order for RBC transfusion in hemodynamically stable, non-bleeding patients with a "Why Give 2 When 1 Will Do?" Choosing Wisely campaign, while also promoting a restrictive hemoglobin threshold (Hb <7 g/dl). This multimodal intervention was implemented across an academic medical center (AMC) with over 950 beds and 10 community hospitals. RESULTS: Between our baseline (CY 2020) and intervention period (CY 2021), single-unit orders increased from 57% to 70% of all RBC transfusion orders (p < .001). The greatest change in ordering practices was at community hospitals, where single-unit orders increased from 46% to 65% (p < .001). Over the same time period, the system-wide mean (SD) Hb result prior to transfusion fell from 7.3 (0.05) to 7.2 g/dl (0.04) (p < .05). We estimate this effort saved over 4000 units of blood and over $4 million in direct and indirect costs in its first year. DISCUSSION: By combining a single-unit default setting in the RBC order with a restrictive hemoglobin threshold, we significantly reduced variation in ordering practices. This effort demonstrates the value of single-unit policies and "nudges" in system-wide patient blood management initiatives.

Determinantes externos de la disponibilidad de sangre / External Determinants of Blood Availability

El acceso universal a las transfusiones de sangre depende de diversos factores localizados dentro y fuera de los servicios de salud. Motivados por ser este un tema infrecuente, el trabajo tiene el objetivo de analizar desde una perspectiva multidimensional y holística los determinantes externos de la disponibilidad de sangre para las transfusiones. El desarrollo socioeconómico constituye un importante factor dinamizador porque condiciona, de cierta manera, la infraestructura del sistema sanitario e incide sobre los factores epidemiológicos, sociodemográficos y jurídicos. A su vez, estos influyen en la organización de las actividades y la complejidad de la asistencia sanitaria, factores que otorgan un sentido positivo o negativo a la disponibilidad de sangre. Tomarlos en consideración al diseñar las políticas de salud relacionadas con el uso de la sangre permite una mayor precisión en las intervenciones locales que contribuyan a mejorar la seguridad de las transfusiones(AU)

Universal access to blood transfusions depends on a number of localized factors both inside and outside health services. Motivated by being an infrequent topic, this work aims to analyze from a multidimensional and holistic perspective the external determinants of the availability of blood for transfusions. Socio-economic development is an important dynamic factor because it conditions, in a certain way, the infrastructure of the health system and affects epidemiological, sociodemographic and legal factors. In turn, these influence the organization of activities and the complexity of health care, factors that give a positive or negative meaning to the availability of blood. Taking them into consideration when designing health policies related to the use of blood allows greater precision in local interventions that contribute to improving the safety of transfusions(AU)

Measuring the Impact of a Blood Supply Shortage Using Data Science.

BACKGROUND: Transfusion medicine is the only section of the clinical laboratory that performs diagnostic testing and dispenses a drug (blood) on the basis of those results. However, not all of the testing that informs the clinical decision to prescribe a blood transfusion is performed in the blood bank. To form a holistic assessment of blood bank responsiveness to clinical needs, it is important to be able to merge blood bank data with datapoints from the hematology laboratory and the electronic medical record. METHODS: We built an interactive visualization of the time from hemoglobin result availability to initiation of red blood cell (RBC) transfusion and monitored the result over a 2-year period that coincided with several severe blood shortages. The visualization runs entirely on free software and was designed to be feasibly deployed on a variety of hospital information technology platforms without the need for significant data science expertise. RESULTS: Patient factors, such as hemoglobin concentration, blood type, and presence of minor blood group antibodies influenced the time to initiation of transfusion. Time to transfusion initiation did not appear to be significantly affected by periods of blood shortage. CONCLUSION: Overall, we demonstrate a proof of concept that complex, but clinically important, blood bank quality metrics can be generated with the support of a free, user-friendly system that aggregates data from multiple sources.

Psychological impact of the COVID-19 pandemic on young professionals in blood banks and transfusion services: A global cross-sectional survey.

BACKGROUND AND OBJECTIVES: The COVID-19 pandemic brought about changes to daily life as measures to contain the spread of the virus increased across the world. The aim of this survey was to assess the psychological impact of the pandemic on young professionals (YPs) in transfusion medicine. MATERIALS AND METHODS: A cross-sectional web-based survey was distributed electronically to ISBT members inviting YPs (≤40 years) to participate. Statistical analysis was performed using SPSS software. RESULTS: Two hundred and fifty-nine YPs completed the survey, including 107 clinicians/physicians and/or nurses. Almost half of the YPs (52.5%) indicated increased stress levels and 15.4% indicated symptoms of depression. YPs highlighted the loss of social engagement (59.1%) and increased pressure from information seen on media (35.5%) as factors negatively impacting their psychological wellbeing. Further, 20.8% expressed increased economic stress resulting from concerns about job security. Almost half of the YPs indicated that their organization provided moderate/occasional holistic support to them and their families. Sixty percent and 74.4% of YPs reported increased workload and staff absence due to COVID-19 infection, respectively. Only half of clinicians/physicians and/or nurses indicated that they often had sufficient personal protective equipment. The majority of these (76.6%) had family/household members living with them, and 61% indicated that they were significantly worried about infecting them because of the nature of their work. CONCLUSION: COVID-19 had a major impact on the well-being of YPs working in transfusion medicine. Measures are required to ensure that YPs are protected and mentally supported while undertaking their duties in current and future pandemics.

Supplemental findings of the 2019 National Blood Collection and Utilization Survey.

INTRODUCTION: Supplemental data from the 2019 National Blood Collection and Utilization Survey (NBCUS) are presented and include findings on donor characteristics, autologous and directed donations and transfusions, platelets (PLTs), plasma and granulocyte transfusions, pediatric transfusions, transfusion-associated adverse events, cost of blood units, hospital policies and practices, and implementation of blood safety measures, including pathogen reduction technology (PRT). METHODS: National estimates were produced using weighting and imputation methods for a number of donors, donations, donor deferrals, autologous and directed donations and transfusions, PLT and plasma collections and transfusions, a number of crossmatch procedures, a number of units irradiated and leukoreduced, pediatric transfusions, and transfusion-associated adverse events. RESULTS: Between 2017 and 2019, there was a slight decrease in successful donations by 1.1%. Donations by persons aged 16-18 decreased by 10.1% while donations among donors >65 years increased by 10.5%. From 2017 to 2019, the median price paid for blood components by hospitals for leukoreduced red blood cell units, leukoreduced apheresis PLT units, and for fresh frozen plasma units continued to decrease. The rate of life-threatening transfusion-related adverse reactions continued to decrease. Most whole blood/red blood cell units (97%) and PLT units (97%) were leukoreduced. CONCLUSION: Blood donations decreased between 2017 and 2019. Donations from younger donors continued to decline while donations among older donors have steadily increased. Prices paid for blood products by hospitals decreased. Implementation of PRT among blood centers and hospitals is slowly expanding.

Maternity health professionals' perspectives of cord clamp timing, cord blood banking and cord blood donation: a qualitative study.

BACKGROUND: Parents today have several options for the management of their infant's cord blood during the third stage of labour. Parents can choose to have their infant's cord clamped early or to have deferred cord clamping. If the cord is clamped early, cord blood can be collected for private cord blood banking or public cord blood donation for use later if needed. If cord clamping is deferred, the placental blood physiologically transfuses to the neonate and there are physiological advantages to this. These benefits include a smoother cardiovascular transition and increased haemoglobin levels while not interfering with the practice of collecting cord blood for gases if needed. The aim of this study is to explore Australian maternity health professionals' perspectives towards cord clamp timing, cord blood banking and cord blood donation. METHODS: Fourteen maternity health professionals (midwives and obstetricians) from both private and public practice settings in Australia participated in semi-structured interviews either in person or by telephone. Interviews were transcribed and data analysed using thematic analysis. RESULTS: Overall there was strong support for deferred cord clamping, and this was seen as important and routinely discussed with parents as part of antenatal care. However, support did not extend to the options of cord blood banking and donation and to routinely informing parents of these options even when these were available at their birthing location. CONCLUSION: Formalised education for maternity health professionals is needed about the benefits and implications of cord blood banking and cord blood donation so that they have the confidence to openly discuss all options of cord clamp timing, cord blood banking and cord blood donation to facilitate informed decision-making by parents.

Lineamientos técnicos para facilitar la asistencia de donantes voluntarios altruistas de sangre a los bancos de sangre del Sistema Nacional Integrado de Salud, en la emergencia nacional por la pandemia de COVID 19 / Technical guidelines to facilitate the assistance of altruistic voluntary blood donors to the blood banks of the National Integrated Health System, in the national emergency due to the COVID 19 pandemic

Ante la emergencia nacional decretada por la pandemia de la enfermedad COVID-19, se ha presentado una considerable reducción de la asistencia de personas donantes voluntarias altruistas de sangre a la Red Nacional de Bancos de Sangre, lo cual a corto plazo, puede ocasionar un desabastecimiento de hemocomponentes que son vitales para la atención de emergencias, así como también en el tratamiento de pacientes con diversas enfermedades en la Red de Hospitales del Sistema Nacional Integrado de Salud. Con el propósito de facilitar que las personas que son donantes voluntarios, puedan asistir a los Bancos de sangre, se elaboran los presentes lineamientos en los cuales se establecen los mecanismos para facilitar el traslado de los donantes, así como también se brindan las indicaciones a seguir por los Bancos de Sangre del Sistema Nacional Integrado de Salud

Given the national emergency decreed by the COVID-19 pandemic, there has been a considerable reduction in the assistance of voluntary altruistic blood donors to the National Network of Blood Banks, which in the short term, may cause a shortage of blood components that are vital for emergency care, as well as in the treatment of patients with various diseases in the Hospital Network of the National Integrated Health System. With the purpose of facilitating that people who are voluntary donors, can attend the blood banks, these guidelines are prepared in which the mechanisms to facilitate the transfer of donors are established, as well as the instructions to follow. by the Blood Banks of the National Integrated Health System

Risk Associated With Autologous Fresh Whole Blood Training.

Fresh whole blood (FWB) is increasingly being recognized as the ideal resuscitative fluid for hemorrhagic shock. Because of this, military units are working to establish the capability to give FWB from a walking blood bank donor in environments that are unsupported by conventional blood bank services. Therefore, many military units are performing autologous blood transfusion training. In this training, a volunteer has a unit of blood collected and then transfused back into the same donor. The authors report their experience performing an estimated 3408 autologous transfusions in training and report no instances of hemolytic transfusion reactions or other major complications. With appropriate control measures in place, autologous FWB training is low-risk training.

Is there a risk of transfusion-transmissible infections after percutaneous needle treatments in blood donors? A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: The donor medical questionnaire identifies a blood donor's history of known blood safety risks. Current Australian, Canadian, European and USA legislation temporarily defers blood donors who received different percutaneous needle treatments (i.e. tattooing, acupuncture and piercing) from blood donation. This systematic review aimed to scientifically underpin these deferrals by identifying the best available evidence on the association between percutaneous needle treatments and the risk of transfusion-transmissible infections (TTIs). MATERIALS AND METHODS: Studies from three databases investigating the link between percutaneous needle treatments and TTIs (HBV, HCV and HIV infection) in blood donors were retained and assessed on eligibility by two reviewers independently. The association between percutaneous needle treatments and TTIs was expressed by conducting meta-analyses and calculating pooled effect measures (odds ratios (ORs) and 95% CIs). The GRADE methodology (Grades of Recommendation, Assessment, Development and Evaluation) was used to assess the quality of evidence. RESULTS: We identified 1242 references and finally included 21 observational studies. Twenty studies assessed the link between percutaneous needle treatments and HCV infection and found that blood donors receiving these treatments had an increased risk of HCV infection (tattooing: pooled OR 5·28, 95% CI [4·33, 6·44], P < 0·00001 (low-quality evidence); acupuncture: pooled OR 1·56, 95% CI [1·17, 2·08], P = 0·03 (very low-quality evidence); and piercing: pooled OR 3·25, 95% CI [1·68, 6·30], P = 0·0005 (low-quality evidence)). CONCLUSION: Percutaneous needle treatments may be associated with an increased HCV infection risk. Further high-quality studies are required to formulate stronger evidence-based recommendations on percutaneous needle treatments as a blood donor deferral criterion.

Detecting Autologous Blood Transfusion in Doping Control: Biomarkers of Blood Aging and Storage Measured by Flow Cytofluorimetry.

BACKGROUND: Blood transfusions are banned by the World Anti-Doping Agency as a form of "blood doping". A method of detection of homologous blood transfusion (HBT) has been implemented by the accredited anti-doping laboratories worldwide; however, no internationally recognized method has been finalized so far for the direct detection of autologous blood transfusions, which can at present be revealed only by targeted longitudinal profiling of key blood parameters. METHODS: The present article reports the results of an investigation aimed to pre-select potential biomarkers of blood aging and storage that can be measured to identify the presence in the sample of reinfused blood. Microparticles from platelets and erythrocytes, erythrocytes size and density, annexin V (as a marker of phosphatidylserine externalization), and the membrane surface antigens CD 55 and CD 59, were specifically considered as potential biomarkers and measured by flow cytofluorimetric techniques. RESULTS AND CONCLUSION: Our results indicate that the parameters more strongly affected by the ex vivo storage of whole blood are erythrocytes size and density, annexin V and microparticles. Although the real diagnostic value of the proposed biomarkers shall obviously be confirmed by further studies carried out on blood samples collected after an actual autologous blood transfusion, these results appear very encouraging towards the development of a direct method for detecting autologous blood transfusion in sport doping.

Very low prevalence of iron deficiency among young French children: A national cross-sectional hospital-based survey.

Although iron deficiency (ID) is considered the most frequent micronutrient deficiency in industrialized countries and is associated with impaired neurodevelopment when occurring in early years, accurate recent estimations of its prevalence are lacking. Our objective was to estimate ID prevalence and associated sociodemographic markers in young children in France. The Saturn-Inf national cross-sectional hospital-based survey recruited 3,831 French children <6 years old between 2008 and 2009 to assess lead poisoning prevalence and to establish a biobank. This secondary analysis measured serum ferritinemia (SF) in sera kept frozen at -80 °C for children with sufficient serum aliquots and C-reactive protein <10 mg/L. For the 657 participating children (17% of the Saturn-Inf study), the median age was 3.9 years (interquartile range: 2.2-5.1); 52% were boys. The median SF was 44 µg/L (interquartile range: 28-71). ID prevalence was 2.8% (95% confidence interval [1.7, 4.7]) and 3.2% (95% confidence interval [2.0, 5.1]) with an SF threshold of 10 and 12 µg/L, respectively. Low SF was significantly associated (p < .05) with mother being a migrant (32 vs. 45 µg/L for a mother born in France) or unemployed (37 vs. 50 µg/L for a mother employed). In this first national cross-sectional hospital-based study in France, ID prevalence was much lower than that in other French and European studies performed in underprivileged populations but close to the lowest values observed in other population-based studies in Europe.

Olive Leaf Extracts Act as Modulators of the Human Immune Response.

BACKGROUND: Olive tree leaves have been used in the Mediterranean area as traditional medicine in virtue of their healthy effects. Olive leaf extracts (OLEs) contain higher amounts of polyphenols than those detected in the extra virgin olive oil and fruit. Several lines of evidence support the cardioprotective, anti-oxidant and anti-inflammatory activities exerted by OLEs. METHODS: Peripheral blood mononuclear cells from twenty-five healthy donors were cultured in the presence of 3 µg of two OLE extracts, extract A (resuspended in water) and extract B (resuspended in 70% ethanol). After harvesting, cell pellets were used for cytofluorimetric phenotyping, while supernatants were assayed for cytokine release by means of ELISA. Furthermore, in the same supernatants nitric oxide (NO) content was determined. RESULTS: Both extracts, but especially extract A, increased absolute numbers of CD8+ and natural killer (NK) cells. In addition, an increased production of interferon (IFN)-γ by both extracts as an expression of T helper (h)1 activation was observed. Finally, both extracts enhanced NO release. CONCLUSION: OLEs, and mostly extract A, are able to in vitro modify healthy human immune response by increasing IFN-γ production which seems to be associated to the higher absolute numbers of CD8+ and NK cells and this may suggest a reinforcement of the anti-tumor activity. Furthermore, increased levels of NO may indicate the potential cardioprotective effects exerted by OLEs in virtue of their vasodilation dependent activity. Finally, OLEs are able to maintain the equilibrium between T regulatory cells and Th17 cells as evidenced by unmodified levels of interleukin (IL)-IL-10 and IL-17, respectively. In the light of these results, OLEs are potential therapeutic compounds for the treatment of chronic inflammatory disease, also preventing cardiovascular event outcome.

Progress in the blood supply of Afghanistan.

BACKGROUND: The blood supply system in Afghanistan was badly damaged by years of conflict. In 2009, the Afghanistan National Blood Safety and Transfusion Service (ANBSTS) was established. STUDY DESIGN AND METHODS: For 6 years, we collaborated to assist with policy and infrastructure development; blood bank operations; blood collection, testing, and component production; transfusion practices; and training of technicians, nurses, midwives, and physicians. RESULTS: Policies were established, infrastructure was strengthened, and capable staff was acquired and trained. Standard operating procedures were developed, testing was improved, and quality systems were established. Thirty trainings were held for blood center staff. Four additional formal trainings were held for 39 physicians, 36 nurses and/or midwives, and 38 laboratory technicians. During 5 years of this project, blood collection increased by 40%. CONCLUSION: The ANBSTS has made impressive progress developing infrastructure, personnel, procedures, quality systems, and training programs and increasing blood collection. Knowledge of transfusion medicine was improved through structured training.

Multidisciplinary In Situ Simulation-Based Training as a Postpartum Hemorrhage Quality Improvement Project.

BACKGROUND: Postpartum hemorrhage is a common obstetric emergency affecting 3 to 5% of deliveries, with significant maternal morbidity and mortality. Effective management of postpartum hemorrhage requires strong teamwork and collaboration. We completed a multidisciplinary in situ postpartum hemorrhage simulation training exercise with structured team debriefing to evaluate hospital protocols, team performance, operational readiness, and real-time identification of system improvements. Our objective was to assess participant comfort with managing obstetric hemorrhage following our multidisciplinary in situ simulation training exercise. METHODS: This was a quality improvement project that utilized a comprehensive multidisciplinary in situ postpartum hemorrhage simulation exercise. Participants from the Departments of Obstetrics and Gynecology, Anesthesia, Nursing, Pediatrics, and Transfusion Services completed the training exercise in 16 scenarios run over 2 days. The intervention was a high fidelity, multidisciplinary in situ simulation training to evaluate hospital protocols, team performance, operational readiness, and system improvements. Structured debriefing was conducted with the participants to discuss communication and team functioning. Our main outcome measure was participant self-reported comfort levels for managing postpartum hemorrhage before and after simulation training. A 5-point Likert scale (1 being very uncomfortable and 5 being very comfortable) was used to measure participant comfort. A paired t test was used to assess differences in participant responses before and after the simulation exercise. We also measured the time to prepare simulated blood products and followed the number of postpartum hemorrhage cases before and after the simulation exercise. RESULTS: We trained 113 health care professionals including obstetricians, midwives, residents, anesthesiologists, nurse anesthetists, nurses, and medical assistants. Participants reported a higher comfort level in managing obstetric emergencies and postpartum hemorrhage after simulation training compared to before training. For managing hypertensive emergencies, the post-training mean score was 4.14 compared to a pretraining mean score of 3.88 (p = 0.01, 95% confidence interval [CI] = 0.06-0.47). For shoulder dystocia, the post-training mean score was 4.29 compared to a pretraining mean score of 3.66 (p = 0.001, 95% CI = 0.41-0.88). For postpartum hemorrhage, the post-training mean score was 4.35 compared to pretraining mean score of 3.86 (p = 0.001, 95% CI = 0.36-0.63). We also observed a decrease in the time to prepare simulated blood products over the course of the simulation, and a decreasing trend of postpartum hemorrhage cases, which continued after initiating the postpartum hemorrhage simulation exercise. DISCUSSION: Postpartum hemorrhage remains a leading cause of maternal morbidity and mortality in the United States. Comprehensive hemorrhage protocols have been shown to improve outcomes related to postpartum hemorrhage, and a critical component in these processes include communication, teamwork, and team-based practice/simulation. As medicine becomes increasingly complex, the ability to practice in a safe setting is ever more critical, especially for low-volume, high-stakes events such as postpartum hemorrhage. These events require well-functioning teams and systems coupled with rapid assessment and appropriate clinical action to ensure best patient outcomes. We have shown that a multidisciplinary in situ simulation exercise improves self-reported comfort with managing obstetric emergencies, and is a safe and effective way to practice skills and improve systems processes in the health care setting.

Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage

"IMPORTANCE: More than 100 million units of blood are collected worldwide each year, yet the indication for red blood cell (RBC) transfusion and the optimal length of RBC storage prior to transfusion are uncertain. OBJECTIVE: To provide recommendations for the target hemoglobin level for RBC transfusion among hospitalized adult patients who are hemodynamically stable and the length of time RBCs should be stored prior to transfusion. EVIDENCE REVIEW: Reference librarians conducted a literature search for randomized clinical trials (RCTs) evaluating hemoglobin thresholds for RBC transfusion (1950-May 2016) and RBC storage duration (1948-May 2016) without language restrictions. The results were summarized using the Grading of Recommendations Assessment, Development and Evaluation method. For RBC transfusion thresholds, 31 RCTs included 12 587 participants and compared restrictive thresholds (transfusion not indicated until the hemoglobin level is 7-8 g/dL) with liberal thresholds (transfusion not indicated until the hemoglobin level is 9-10 g/dL). The summary estimates across trials demonstrated that restrictive RBC transfusion thresholds were not associated with higher rates of adverse clinical outcomes, including 30-day mortality, myocardial infarction, cerebrovascular accident, rebleeding, pneumonia, or thromboembolism. For RBC storage duration, 13 RCTs included 5515 participants randomly allocated to receive fresher blood or standard-issue blood. These RCTs demonstrated that fresher blood did not improve clinical outcomes. FINDINGS: It is good practice to consider the hemoglobin level, the overall clinical context, patient preferences, and alternative therapies when making transfusion decisions regarding an individual patient. Recommendation 1: a restrictive RBC transfusion threshold in which the transfusion is not indicated until the hemoglobin level is 7 g/dL is recommended for hospitalized adult patients who are hemodynamically stable, including critically ill patients, rather than when the hemoglobin level is 10 g/dL (strong recommendation, moderate quality evidence). A restrictive RBC transfusion threshold of 8 g/dL is recommended for patients undergoing orthopedic surgery, cardiac surgery, and those with preexisting cardiovascular disease (strong recommendation, moderate quality evidence). The restrictive transfusion threshold of 7 g/dL is likely comparable with 8 g/dL, but RCT evidence is not available for all patient categories. These recommendations do not apply to patients with acute coronary syndrome, severe thrombocytopenia (patients treated for hematological or oncological reasons who are at risk of bleeding), and chronic transfusion-dependent anemia (not recommended due to insufficient evidence). Recommendation 2: patients, including neonates, should receive RBC units selected at any point within their licensed dating period (standard issue) rather than limiting patients to transfusion of only fresh (storage length: <10 days) RBC units (strong recommendation, moderate quality evidence). CONCLUSIONS AND RELEVANCE: Research in RBC transfusion medicine has significantly advanced the science in recent years and provides high-quality evidence to inform guidelines. A restrictive transfusion threshold is safe in most clinical settings and the current blood banking practices of using standard-issue blood should be continued."

Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage.

Importance: More than 100 million units of blood are collected worldwide each year, yet the indication for red blood cell (RBC) transfusion and the optimal length of RBC storage prior to transfusion are uncertain. Objective: To provide recommendations for the target hemoglobin level for RBC transfusion among hospitalized adult patients who are hemodynamically stable and the length of time RBCs should be stored prior to transfusion. Evidence Review: Reference librarians conducted a literature search for randomized clinical trials (RCTs) evaluating hemoglobin thresholds for RBC transfusion (1950-May 2016) and RBC storage duration (1948-May 2016) without language restrictions. The results were summarized using the Grading of Recommendations Assessment, Development and Evaluation method. For RBC transfusion thresholds, 31 RCTs included 12 587 participants and compared restrictive thresholds (transfusion not indicated until the hemoglobin level is 7-8 g/dL) with liberal thresholds (transfusion not indicated until the hemoglobin level is 9-10 g/dL). The summary estimates across trials demonstrated that restrictive RBC transfusion thresholds were not associated with higher rates of adverse clinical outcomes, including 30-day mortality, myocardial infarction, cerebrovascular accident, rebleeding, pneumonia, or thromboembolism. For RBC storage duration, 13 RCTs included 5515 participants randomly allocated to receive fresher blood or standard-issue blood. These RCTs demonstrated that fresher blood did not improve clinical outcomes. Findings: It is good practice to consider the hemoglobin level, the overall clinical context, patient preferences, and alternative therapies when making transfusion decisions regarding an individual patient. Recommendation 1: a restrictive RBC transfusion threshold in which the transfusion is not indicated until the hemoglobin level is 7 g/dL is recommended for hospitalized adult patients who are hemodynamically stable, including critically ill patients, rather than when the hemoglobin level is 10 g/dL (strong recommendation, moderate quality evidence). A restrictive RBC transfusion threshold of 8 g/dL is recommended for patients undergoing orthopedic surgery, cardiac surgery, and those with preexisting cardiovascular disease (strong recommendation, moderate quality evidence). The restrictive transfusion threshold of 7 g/dL is likely comparable with 8 g/dL, but RCT evidence is not available for all patient categories. These recommendations do not apply to patients with acute coronary syndrome, severe thrombocytopenia (patients treated for hematological or oncological reasons who are at risk of bleeding), and chronic transfusion-dependent anemia (not recommended due to insufficient evidence). Recommendation 2: patients, including neonates, should receive RBC units selected at any point within their licensed dating period (standard issue) rather than limiting patients to transfusion of only fresh (storage length: <10 days) RBC units (strong recommendation, moderate quality evidence). Conclusions and Relevance: Research in RBC transfusion medicine has significantly advanced the science in recent years and provides high-quality evidence to inform guidelines. A restrictive transfusion threshold is safe in most clinical settings and the current blood banking practices of using standard-issue blood should be continued.

[Control of potential risk in blood establishments in Brazil: a strategy for regulating authorities]. / Controle de riscos potenciais em serviços de hemoterapia no Brasil: uma abordagem para autoridades reguladoras.

Objective To describe the sanitary status of Brazilian blood establishments (BE) assessed by the national health surveillance system in 2013. Method In the present descriptive study, the sanitary profile of BE was assessed using the Blood Establishment Potential Risk Assessment Method (Método de Avaliação de Risco Potencial de Serviços de Hemoterapia, MARPSH), developed by the National Sanitary Surveillance Agency (Anvisa). The MARPSH involves the evaluation of 471 structure and process items to produce an assessment of potential risk associated with critical control points in the blood cycle (vein-to-vein). Based on this assessment, BE are classified into five risk categories: low, medium-low, medium, medium-high, and high. The results were analyzed regarding the type of service (considering all levels, from coordinating centers to collection units), type of financing (public/private) and geographic region. Results Of the existing BE, 1 212 (60%) were assessed in 2013. Of these, 81% met ≥ 70% of the sanitary requirements (satisfactory status, corresponding to medium, medium-low, and low risk categories). Transfusion agencies (hospital units with the role of storing, running compatibility tests between donors and recipients, and transfusing blood components) and public establishments had the highest number of non-conformity structure and process items. Conclusion The use of the MARPSH facilitated the assessment of BE in Brazil and revealed objective opportunities for improvement. These gaps should be addressed by regulating authorities, especially in public services.

[Positive Coomb's test in newborns; causes and clinical consequences Summary of cases diagnosed in the Blood Bank in the years 2005 to 2012].

INTRODUCTION: Hemolytic disease of the fetus and newborn (HDFN) is caused by the destruction of fetal red blood cells due to red cell antibodies produced by the mother. HDFN can cause fetal hydrops during pregnancy or neonatal jaundice after birth. Direct Antiglobulin Test (DAT) detects antibodies bound to red cells and is a valuable test aiding in the diagnosis of HDFN. In Iceland DAT is routinely performed on cord blood or newborn blood samples if the mother is Rhesus D negative or has non-A/B red cell alloantibodies. The aim of this study was to investigate the causes and consequences of positive DAT in newborns in Iceland over a period of eight years. MATERIAL AND METHODS: The study population was infants diagnosed with a positive DAT in the Blood Bank in Iceland in the years 2005-2012. Relevant data on the blood group and antibody status of mother and child, blood transfusion and DAT results were retrieved from the Blood Bank information system ProSang. Birth records provided information on birth weight, gestational age and phototherapy. Health records from the Children's Hospital provided information on the management and fate of the newborn. RESULTS: Over the study period 383 newborns had a positive DAT result at the Blood Bank. In 73.6% of cases the underlying cause was ABO blood group mismatch between mother and infant, in 20.4% of cases the mother had non-A/B red cell alloantibodies, in 3.9% both of above factors were present, while in 2.1% the cause was unclear. A total of 179 (47.6%) children had neonatal jaundice that required treatment, of which 167 (93.3%) only needed phototherapy. Eight infants required exchange transfusion, five of these had Rhesus antibodies and three ABO blood group mismatch. CONCLUSION: ABO blood group mismatch between mother and child was the most common cause for a positive DAT in neonates in Iceland in the years 2005-2012. Almost half of the neonates required treatment but usually phototherapy was sufficient. Rarely, blood transfusion or exchange transfusion was necessary in severe cases of ABO blood group mismatch or non-A/B red cell alloantibodies. KEY WORDS: Coombs test, Direct Antiglobulin Test (DAT), Hemolytic disease of the fetus and newborn (HDFN), ABO blood group mismatch, red cell alloantibodies, neonatal jaundice, exchange transfusion. Correspondence: Anna Margret Halldorsdottir, annamha@landspitali.is.